AtiE-UNIVERto - <\\IEUNIVER% A CONTRIBUTION TO THE SURGERY OP THE SPINAL CORD. A CONTKIBUTION TO THE SURGERY OF THE SPINAL CORD. BY WILLIAM THORBURN, B.S., B.Sc., M.D. (LOND.) FELLOW OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND ; SURGICAL REGISTRAR TO THE MANCHESTER ROYAL INFIRMARY; FORMERLY SURGICAL TUTOR TO THE OWENS COLLEGE, MANCHESTER. IHHitb Diagrams, Illustrations, and Gables. PHILADELPHIA: BLAKISTON, SON AND CO. 1012 WALNUT STREET. 144382 400 9c INTKODUCTION. IN the following pages will be found recorded a number of clinical observations, chiefly upon injuries of the spinal cord, and certain other traumatic affections, formerly supposed to be of organic and spinal origin, but now generally attributed to a totally different form of nervous disturbance. Although many of these observations have been already published in various medical journals, yet the present book is by no means a mere --' i reprint, inasmuch as the arrangement adopted, and the con- necting links of thought here supplied, not only render the JQ result an extension of previous work, but give to it a coherence Diaphragm Serratus 1 Shoulder Shoulder Flexorsof elbow | muscles Sixth cervical ) Supinators i Extensors of wrist and Lower neck muscles Seventh cervical . fingers (Extensors of elbow Arm Flexors of wrist and fingers Middle part of trapezius Eighth cervical . First dorsal Pronators j Muscles of hand Hand (uhiar n. lowest) 1 Diseases of the Nervous System, vol. i. p. 142. INJURIES TO THE CERVICAL REGION. 3 Herringham, 1 examining their relations from a pm-ely anatomi- cal point of view, has in the human subject carefully dissected the cervical nerve-roots through the brachial plexus, and has obtained the following results as to their distribution : Fifth cervical root : Biceps, brachialis anticus, subscapularis, deltoid. Sixth cervical root : Pectoralis major, biceps, brachialis anticus, pronator teres, flexor carpi radialis, superficial thenar muscles, subscapularis, teres major, deltoid, supinator longus et brevis, extensor carpi radialis longior et brevior. Seventh cervical root: Pectoralis major et minor, coraco- brachialis, flexor sublimis, latissimus dorsi, triceps, extensor carpi radialis longior et brevior. Eighth cervical root : Pectoralis major et minor, flexor sub- limis, latissimus dorsi, triceps. First dorsal root : Pectoralis major et minor. This anatomical method of investigation would appear to be less open to objection than any other, and the general conclusions will be found to accord fairly well with those previously obtained ; the most important difference being that the intrinsic muscles of the hand are assigned a higher level of origin than in the experi- mental and clinical observations. The result is, however, not a perfect clinical guide, inasmuch as the connections are too minute, branches evidently being traced into muscles for which they do not contribute any important path of voluntary impulses, and the paralysis or irritation of which will, therefore, not be productive of any symptoms. An accurate knowledge of these localisations being of the greatest importance to the surgeon who would operate for the relief of pressure lesions of the spinal cord, I have endeavoured to work out an independent scheme by observing in detail the extent of the paralysis and anaesthesia in cases of injury, both at an early period, and also during the progressive ascending myelitis which usually ensues. The extent of the paralysis has been deduced partly from the obvious loss of voluntary control over the muscles, partly from the positions assumed by the limbs, and partly from the electric reactions. The exact site of the lesion has generally been subsequently confirmed by post- mortem examination. Following out this method, I have been led to arrange the 1 Proc. Roy. Soc., No. ccxliii., 1886, p. 255. 4 SURGERY OF THE SPINAL CORD. various spinal muscular nuclei in the following order, from above downwards, assigning each to the nerve-root by which its efferent fibres probably leave the cord : Supraspinatus and infraspinatus Teres minor (?).... ( Biceps ( Brachialis anticus 1 . Deltoid ( Supinator longus . ( Supinator brevis (?) Subscapularis . Pronators Teres major . Latissimus dorsi . Pectoralis major . l Triceps ( Serratus magnus . Extensors of the wrist Flexors of the wrist Interossei . Other intrinsic muscles of the hand Fourth cervical nerve. Fifth cervical nerve. > Sixth cervical nerve. Seventh cervical nerve. Eighth cervical nerve. [ First dorsal nerve. In endeavouring to elucidate this matter, I have entirely ignored the results arrived at by other methods, and have con- fined myself entirely to the evidence yielded by the cases referred to, the more so as the conclusions are consistent with the majority of previous observations. It will be obvious that the method adopted, relying, as it does, principally upon the position and mobility of the limbs, indicates only the chief point of origin of the motor nerve-fibres for each muscle, and that where muscles are supplied from more than one level or root, the minor connections are disregarded. Thus, in the case of the pectoralis major, there is no doubt that several roots supply the muscle, but of these one only could be identified. The conclusions, however, although probably thus wanting in minute accuracy, will obviously be of the more value as clinical data, and are not open to the objections presented by Herringham's more complete scheme. Time alone will explain the minor dis- crepancies between my arrangement and those of others. While narrating the following cases in the order best suited to illustrate the above table, I shall refer from time to time to other points of interest which they present. 1 I have not identified the brachialis anticus, but, from well-known clinical facts, assume it to be in close connection with the biceps. INJURIES TO THE CERVICAL REGION. 5 CASE i. Fracture-dislocation between the fourth and fifth cervical vertebras Complete paralysis of limbs and trunk Death. The following case was under the care of Mr. Heath. The notes were taken by the dresser, Mr. W. H. Iddon. M. L., male, aged forty-five, was admitted to the Manchester Infirmary on March 27, 1 8 86. He had fallen from a scaffolding some forty feet in height. In addition to three lacerated scalp- wounds, he presented the following symptoms. There was severe pain in the back of the neck. All four extremities were " com- pletely paralysed," as were the muscles of the trunk and abdomen. The limbs and trunk were absolutely anaesthetic below a line running across the thorax at the level of the second intercostal space, and thence across the deltoids at the junction of their upper and middle thirds ; above this line sensation was normal, the transition being quite abrupt. The pupils were equal, and were thought to be of normal size. There was no mental affection. Respiration was diaphragmatic ; the urine was retained ; priapism was constant. Death took place a few hours after admission, apparently from dyspnoea. The temperature was taken several times, but was unfortunately not recorded. The house-surgeon assures me that it was certainly not, at any time, far from the normal. At the post-mortem examination there was found a fracture through the body of the fifth cervical vertebra and the inter- vertebral disc immediately above it. The spines of the third, fourth, and fifth vertebras were broken off. Around the dura mater at this point was a very slight effusion of blood. The cord was much lacerated, being almost torn across opposite the seat of fracture, and was very soft for a distance of nearly i^ in., being reddened by extravasated blood. The skull and its contents were uninjured. The lungs were oedematous. Here we have a lesion affecting the junction of the fourth and fifth cervical vertebrae, so that the fifth root, which escapes from the spinal canal above the fifth vertebra, would be injured together with the cord itself below this point. Hence we get complete paralysis of sensation and motion in the upper extremity, the whole of the brachial plexus being cut off from the brain, with the exception of its branch from the fourth cervical nerve. The present case unfortunately yields no evidence as to the distribu- tion of this branch, the condition of the posterior scapular muscles not having been specially noted. SURGERY OF THE SPINAL CORD. CASE 2. Dislocation between the fourth and fifth cervical vertebras Complete paralysis of limbs and trunk Death. C. D. was admitted under the care of Mr. Hardie, the notes being taken by Mr. Benson, house-surgeon. The patient, a carter, thirty-nine years of age, was admitted on August 3, 1886, having fallen from a van, of which the wheels had passed over his shoulders. On admission he complained of great pain at the back of the neck. All four limbs were completely paralysed, and there was anaesthesia below the level of the descending branches of the cervical plexus. Respiration was diaphragmatic. The fasces were passed unconsciously. Both pupils were contracted, the palpebral fissures narrowed, and the eyeballs presented a remarkable sensa- tion of softness owing to paralysis of the posterior orbital muscles. The pulse was full, of low tension, and beating at the rate of 60 per minute. The temperature on the evening of admission was 96.8. He passed a restless night, and on the next morning the following additional symptoms were noted. There was constant priapism. The urine was retained, and upon being withdrawn by the catheter, was examined for sugar and albumin, with negative results. The face was much congested ; the pulse remained full and soft, beating at the rate of 130 per minute. The tempera- ture at 8 A.M. was 102.2. When the patient was told to take a deep breath, he contracted the levator anguli scapulae muscles, which could be distinctly felt beneath the trapezius, thus indicating an attempt to fix the scapula, and bring into pluy the extraordinary muscles of inspiration. At 10 A.M. the patient's temperature had risen to 103.6 ; at midday to 105; at 2 P.M. to 106. At 4 P.M. it was 107.8. He now became insensible and livid, and the breathing was more shallow, the whole body being covered with a profuse hot sweat. At 5 P- M - he died, the temperature having risen to 108. The temperature after death was not recorded. At the post-mortem examination there was found a rupture of the cartilage between the bodies of the fourth and fifth cervical vertebrae, these two bodies being so widely separated behind that a finger could be introduced between them. They thus formed an obtuse angle posteriorly, pressing on the contents of the spinal canal. At this point there was marked post-mortem staining of the meninges, but decomposition was so far advanced that it could INJURIES TO THE CERVICAL REGION. 7 not be ascertained whether they were inflamed. The cord itself was here compressed, through a vertical extent of three-quarters of an inch, into a narrow band, and was very much softened, there being no distinction between the grey and the white matter. Elsewhere the cord showed only post-mortem softening. The posterior parts of both lungs were much congested, and in the brain were numerous puncta cruenta. There were no other changes of interest. This case is similar to the last, the lesion again involving the roots of the fifth cervical nerves and all parts below them, and the symptoms being the same. Both cases are of value mainly as contrasting with those which follow. CASE 3. Fracture-dislocation between the fifth and sixth cervical vertebrae Complete paralysis of all nerves below the fifth cer- vical Death, L. F. was admitted to the Manchester Royal Infirmary under the care of Mr. Jones on June 5, 1886. The patient was a man, aged sixty-eight, a labourer by occupation. On June I, four days before admission, he was standing on a short ladder whitewashing, when, two of the rungs of the ladder giving way, he fell backwards in such a position that while his feet remained caught in the ladder, he first struck the back of his neck against a bench some 2^ feet above the ground, and then fell head first to the ground. At the same time he thinks that his bucket of whitewash fell upon him. He at once became unconscious, remaining so for several hours. On regaining consciousness, he found that his legs were quite immovable and his arms partially so, while there was loss of sensation in the lower portion of the body, coupled with a dull aching pain. There was also great pain in the head, neck, and shoulders. The urine had to be drawn off twice daily. He remained in this condition until his admission to the Infirmary on the fourth day after the accident. When admitted, he was found to present complete paralysis of the lower limbs and of the abdominal and thoracic muscles. All the muscles of the arms were paralysed, with the exception of the biceps, brachialis anticus, supinator longus, and deltoid ; the con- sequence being that the elbows were flexed, the shoulders abducted and rotated outwards, and the hands and arms fell into the 8 SURGERY OF THE SPINAL CORD. position indicated in the annexed engraving (fig. i), taken from a photograph. There was no power of extension of the forearm, but a fair degree of power of flexion. Some external rotation of the humerus could be effected by the supra- and infra- spinati. The pectoralis major and latissimus dorsi were paralysed. The lower limbs and trunk were completely anaesthetic as high as the level of the second rib in front i.e., as high as the descend- ing branches of the cervical plexus and apparently to the third dorsal vertebra (?) behind. Above this point sensation was nor- mal. The upper extremities were anaesthetic, with the excep- tion of the radial side of the forearm and hand and the balls of the thumbs. All the cutaneous reflexes and tendon reactions were absent throughout. Breathing was entirely diaphragmatic. \ Fio. i. Position occupied by the limbs in a case of complete transverse destruction of the spinal cord immediately below the level of origin of the fifth cervical nerves. The urine was retained, and the bowels had not been moved since the accident. The penis was subject to frequent erec- tions with seminal emissions ; on the back were several bed- sores. The pulse was slow and full ; the temperature 98. The pupils were both somewhat contracted. Over the fifth and sixth cervical vertebrae was a slight prominence, which was very tender on pressure. The only treatment adopted was complete rest on a water-bed, catheterisation at intervals, and some simple dressing for the bed-sores. During the progress of the case there were not many very important deviations from the symptoms above described. The urine, which was at first healthy, became turbid and alkaline a few days after admission. After this the bladder was washed out daily with boracic acid lotion. Priapism became more constant. The INJUEIES TO THE CERVICAL KEG10N. 9 bowels were never moved except after the use of an enema or of croton-oil. On June 9, four days after admission, the arms had become completely anaesthetic, and they thereafter remained so. The temperature was generally slightly below the normal ; the pulse was often 50, never above 60. Respiration was rapid throughout, being usually about 20, sometimes 30 per minute. The patient's strength failed steadily, and at times there was confusion of thought, with low muttering delirium at night. He complained mainly of pain in the neck and of cold feet. On June I 5 he had lost all power of rotating the humerus on both sides, any passive movement of the shoulder-joints being very painful. The cheeks fell in and out very markedly on respira- tion. Although the power of the voice remained good, speech was almost unintelligible; he could not protrude the tongue beyond the teeth, nor freely open the mouth. There was marked fibrillar trembling of the masseters, and much accumulation of tenacious saliva about the mouth. Bed-sores had formed over the sacrum, on the inner side of the right thigh, and on the inner side of the left knee, these having hardly changed since admission. On June 1 7 the contraction of the deltoid muscles, which had maintained the abducted position of the arms, ceased, and the elbows fell to the sides, the elbow-joints themselves remaining flexed. From this date the patient gradually sank, respiration becoming more laboured, and the countenance dusky, while there was in- creased apathy. On June 25 the pupils were noted as being dilated and unequal, the right being the larger ; there was a commencing " bed-sore " on the chest ; on washing out the bladder there came away shreds of what was thought to be mucous mem- brane. On June 26 he died exhausted. At the post-mortem examination the disc between the fifth and sixth vertebrae was found to be broken across, the lower part of the body of the fifth vertebra being tilted forwards. The laminae were uninjured, but the right superior articular process of the fifth vertebra, and the corresponding transverse process of the sixth were broken off. At this point the cord was compressed, being flattened for a distance of about a quarter of an inch. The dura mater was here yellowish and opaque, the arachnoid and pia mater healthy. The cord was much softened for a distance of two or three inches above and one inch below the seat of injury, especially around the central canal, where it was quite diffluent and of a yellowish colour, showing under the microscope numerous granule-cells. The rest of the cord was healthy. The bladder IO SURGERY OF THE SPINAL CORD. contained a quantity of blood-stained turbid fluid, its mucous membrane hanging in shreds, beneath which the wall was dark and livid ; inflammation had extended to the pelvic cellular tissue and the peritoneum. The kidneys were congested, and presented numerous scattered points of suppuration ; there was no dilation of nor suppuration in their pelves. The other organs presented nothing of interest. This case is a sufficiently typical example of injury to the spinal cord above the origin of the sixth cervical nerves. Thus we find that, with the exception of the biceps, brachialis anticus (?), and supinators, there was absolute paralysis of the intrinsic muscles of the upper extremity. Of the extrinsic muscles of the upper limb, the only ones not paralysed were the deltoid and the external rotators of the humerus the teres minor and spinati. The case is thus an exact counterpart of the so-called Erb's para- lysis, in which we meet with paralysis of the same muscles which were here spared ; and it enables us to confirm previous researches as to the distribution of the fifth cervical nerve-root. From the unopposed action of the above-mentioned muscles there resulted the characteristic position represented in the figure, but how far this contraction was due to mere tonus, and how far to pathological spasm, it is impossible to say. The characteristic position of the limbs observed in this case has been previously noted, but its import has not, I believe, been hitherto fully explained. Thus, in the London Hospital Reports for 1866, Mr. Jonathan Hutchinson mentions a case in which a man had partial paralysis of the right arm, but could raise the limb, although he could not grasp ; and the position is still more clearly indicated in another case, recorded in the same paper, of a crush opposite the fifth cervical vertebra, in which the arms were raised to a level with the shoulders, and the forearms flexed by the biceps. Again, in the St. Thomas's Hospital Reports for 1870, Mr. Churchill describes a case of fracture of the fifth cervical arch, with crushing of the cord, in which the patient could move the shoulders and upper arms only. In the latter paper is also described a case of dislocation forwards of the sixth cervical ver- tebra, in which there was impaired movement of the arms, attri- buted to a desire to keep the spine immovable : the upper arms are described as being raised to a right angle with the body, and " the forearms were flexed so as to relax the muscles and to support the head ; " the same case apparently presented hyper- INJURIES TO THE CERVICAL REGION. I I aesthesia of the radial side of the upper limbs. Clearly, then, this was an example of irritation of the region of origin of the fifth roots, with paralysis below that level. Besides illustrating the functions and distribution of the fifth cervical root, our case suggests that the deltoid nuclei are situated below those for the biceps, the former having first yielded to the ascending myelitis. This suggestion will be found to be confirmed by other cases mentioned below. As regards sensation, we find that a cord lesion which cuts off the origin of all the nerves of the brachial plexus below the fifth cervical causes anaesthesia of the entire upper limb, except the outer side of the arm and forearm, and the radial border of the thumb, i.e., a part of the region supplied by branches of the musculo-spiral nerve. The affection of speech and other symptoms noted in the pro- gress of the above case at first gave rise to the supposition that there might be some extension of myelitis to the medulla oblon- gata ; but as no further symptoms of bulbar paralysis developed themselves, and as the intermediate cervical muscles were un- affected, these phenomena would appear to have been due to the general debility only. CASE 4. Fracture-dislocation between the fourth and fifth cervical vertebrce Partial paralysis of right upper limb Total para- lysis of other limbs and trunk Death. T. L. was admitted under the care of Mr. Heath on September 7, 1886. He was thirty-six years of age, and a carter by occu- pation. While attending to his horse the animal had fallen against him, crushing him against the manger, the corner of which struck his back between the shoulders. He immediately fell down paralysed. On admission, there was found no external bruise or other evidence of injury, except a sense of soreness and stiffness in the lower cervical spine ; no irregularity of the spinous processes could be detected. The lower limbs and trunk muscles were entirely paralysed, as was also the left upper extremity ; the right upper extremity was paralysed, with the exception of the deltoid and biceps (the condition of the brachialis anticus and supinator longus is not noted). The bladder and sphincter ani were also paralysed, and there was priapism. There was anaesthesia of the lower limbs and trunk, and of the upper limbs with the exception of the radial side of the hand, fore- 12 SURGERY OF THE SPINAL CORD. arm, and arm on both sides. Breathing was entirely diaphrag- matic. The pupils were widely dilated. The temperature was I OO.6. The treatment consisted in the use of a water-bed with ice-tubes to the spine, doses of ext. ergot, liq. three times daily, and catheterisation. * At 8 A.M. on the following day the temperature had risen to 105.2; at noon it was 104; and then again gradually rose, reaching 105.6 before death, which occurred on the second day. Breathing became more difficult, with accumulation of mucus in the bronchial tubes, and the face grew very livid. The man died asphyxiated about thirty-six hours after admission, the heart continuing to beat for some ten minutes after respiration had stopped. At the post-mortem examination there was found a rupture of the cartilage between the fourth and fifth cervical vertebrae, " which fracture had extended across posteriorly, involving the laminae of the fourth or fifth vertebrae," but was unaccompanied by any displacement. The spinal membranes were healthy. The cord opposite the seat of fracture was not at all compressed, but was for a distance of about an inch very soft and pulpy, containing numerous punctiform haemorrhages, which were most marked in the central grey matter. The other organs were not examined. This case presents an interesting comparison with Case 3 on the one hand, and with Cases I and 2 on the other. The lesion of the spine itself was less severe, and there was less displacement of the bones, which consequently did not cause permanent com- pression of the cord. There was, however, ample evidence of a temporary crush of the spinal cord, received, no doubt, at the time of injury, the bones afterwards partially recoiling to their normal position. Such, doubtless, is the explanation of many cases (as, for instance, those referred to in the following chapter), in which there is little or no evidence of bone-lesion, but in which the cord itself has sustained a severe injury. An accident causes an acute bend of the vertebral column, which at once rights itself, but not before great or irreparable damage has been inflicted upon the con- tained organ ; and many of these cases have been regarded as in- stances of "concussion of the spinal cord," the possibility of a gross mechanical lesion being overlooked. Another point which is here exemplified, but which is more fully demonstrated in Case 1 6, is the tendency for haemorrhage into the spinal cord to affect mainly its central portions, where its substance is softest, and where the large branches of the central spinal artery have their distribution. INJURIES TO THE CERVICAL REGION. 13 As regards the distribution of the paralysis and anaesthesia in this case, we find that there was not complete annihilation of the functions of the two fifth cervical nerves, their roots not having been severely nipped between the affected bones, although the cord below their origin was crushed. On the left side the upper limb was completely paralysed, as in Cases I and 2, but on the right side some of the muscles supplied by the upper root of the brachial plexus had partially escaped, the biceps and deltoid not beiug paralysed. The supinators were, however, paralysed on this side also, a result perfectly explicable on the supposition that, occupying the lowest nucleus connected with the fifth root, they would most readily come within the sphere of pressure due to the central haemorrhage immediately below. Further, we find that, as in Case 3, so here, sensation was retained on the outer border of the arm, forearm, and hand of both sides, the sensory conducting paths of the left side having been destroyed up to a rather lower level than were the motor functions. Such damage as was done to the area of the fifth roots must therefore be ascribed to the central haemorrhage rather than to injury of the roots themselves. CASE 5. Comminuted fracture of fifth and sixth cervical vertebra; Partial paralysis of left upper limb Total paralysis of other limbs and trunk Death. W. H. was admitted to Mr. Whitehead's wards on April 30, 1886. He was twenty-eight years of age, a wine merchant by occupation, and of intemperate habits. When admitted, he was intoxicated, and had, while in that condition, fallen over the railing of a staircase, the distance not being ascertained. He complained of great pain at the back of the neck, but there were no external signs of injury. There was complete paralysis of both lower extremities and of the right upper limb, but on the left side he could bend the elbow-joint. Respiration was diaphrag- matic. The cutaneous reflexes and tendon reactions were abolished. Anaesthesia was complete below the distribution of the branches of the cervical plexus, except over a portion of the left upper limb. The pupils were moderately contracted, the contraction or rather imperfect dilatation showing best, as is usual in these cases, in diffused light ; the palpebral fissures were small. The pulse was slow and compressible. The temperature was not recorded, but was below the normal. The urine was retained, and the penis large and turgid. 14 SURGERY OF THE SPINAL CORD. A more complete examination showed that although there was absolute loss of motion and sensation in the right upper extre- mity, the paralysis had on the left side spared the deltoid, biceps, brachialis anticus (?), and supinator longus ; the pectoralis major and latissimus dorsi, and all the muscles below the shoulder, with the exception of those mentioned, were paralysed. The limb occu- pied exactly the position assumed by those of Case 3, being slightly abducted at the shoulder, rotated outwards, with the elbow flexed and the forearm and hand supine, the contrast between this position and the complete flaccidity of the right upper extremity being very striking. This was the first case in which this remarkable position of the limb was noted in the Manchester Infirmary, the detection of its significance being due to Mr. Collier, then resident surgical officer. Anassthesia ex- tended over the whole of the left upper extremity, except a strip of skin, some three inches wide, extending downwards from the shoulder along the outer side of the limb to a point about three inches below the level of the elbow-joint. The patient complained much of difficulty of breathing, which increased rapidly, and he died asphyxiated about forty hours after the accident. Before death the temperature became very Fio. 2. Third, fourth, fifth, sixth, and seventh , i cervical vertebrae from Case 5, seen from nigD. the front, showing a comminuted fracture A , , i . _._j._, of the bodies of the firth and sixth verte- At tne post-mortem examina- tion, which was made by Dr. Bury, then medical registrar, there was found a complete crush of the body of the fifth cervical vertebra, that of the fourth being displaced downwards and forwards, and having its left transverse and arti- cular processes broken off, and that of the sixth being split vertically. The condition of the bones is shown in fig. 2. In front of the bodies of the injured vertebrae was some extravasation of blood. On opening the spinal canal, the cord was found to be obliquely compressed by the bony fragments in such a way that the upper limit of the flattening was above the fifth cervical nerve- root on the right side, but between that and the sixth nerve-root on the left, as shown in fig. 3, a small piece of the body of the INJURIES TO THE CERVICAL REGION. fifth vertebra pressing upon the origin of the fifth root of the right side. The lungs were intensely congested, and portions of the left lower lobe sank when thrown into water. The other organs presented nothing of interest. This case, like the preceding one, is an instance of oblique injury to the cord, the direction of the obliquity being re- versed, and the fifth root escaping on the left side only ; and it thus offers another illustration of the distribution of the motor and sensory branches of this root. The area in which sensation was retained was less than in Cases 3 and 4, owing possibly to some of the lower sensory fibres of the left fifth root being also in- volved in the lesion. CASE 6. Injury to upper part oflracliial region Paralysis below deltoid nuclei Death. FIG. 3. Spinal cord from Case 5, seen from behind, showing compression, extending obli-, quely from above the origin of the sixth cervical nerve on the left side, upwards, so as to intercept the fifth nerve- root on the right side. A man aged thirty-five was admitted under Mr. Heath's care on June 18, 1887. He had the night before admission fallen down about ten steps on to his head, as evidenced by bruises on the left side of the cranium. As he died in a few hours, I was obliged to obtain my information from Mr. Thompson, the house- surgeon. At the back of the neck was a large amount of effused blood, but the spines of the vertebrae were distinctly felt, that of the sixth cervical being apparently displaced slightly to the right. Beyond this there was no deformity, nor any difficulty in movement, and the man complained of but slight pain in the back of the neck. The lower limbs and trunk were completely paralysed ; the arms were held rigid with the elbows abducted, and the hands lying on the epigastrium extended and prone. Anaesthesia was complete below a point about two inches above the nipples, being also complete over the shoulders and in the upper limbs. The pupils were reduced to fine points. The urine was retained and the penis turgid. 1 6 SURGERY OF THE SPINAL CORD. As the man was being placed in bed, respiration became slow and gasping, with distinct action of the scaleni and sterno- mastoids; the patient grew cyanotic and respiration then stopped, the pulse ceasing about half a minute later. There was no post- mortem examination. The above case carries us but little further, but it is clear from the facts adduced, and especially from the anaesthesia affect- ing the whole surface of the upper limbs, that almost the entire brachial region was affected. With the exception of the abduction of the shoulders and flexion of the elbows, the arms were in the position of rest, resulting from complete paralysis. Hence then the biceps and deltoid had escaped, but the supinators and all muscles mentioned below them in our table were paralysed that is to say, the ha3morrhage resulting from the crush of the cord had extended partially into the territory of the fifth root, destroy- ing the nuclei, at its lower part, for the supinators, but sparing the biceps and deltoid above. This, and other cases, such as our fourth, indicate that the branches to the supinators have the lowest origin of the " fifth root group " of nerves, these being often implicated when the remainder of the root escapes paralysis. CASE 7. Injury to upper part of brackial region Paralysis below biceps nuclei Death. A. B., aged twenty-three, was admitted to the Manchester Infirmary under the care of Mr. Jones on April 7, 1888. He was playing football, and, while stooping forwards with his head thrown up in order to " tackle " an opponent, came into violent collision, his head being jerked backwards. He was immediately paralysed. On admission, the spine of the seventh cervical vertebra was felt to be distinctly depressed, but with little or no lateral dis- placement. There was a good deal of swelling about the back of the neck, and the patient complained of great pain. The lower limbs and trunk were completely paralysed, respiration being diaphragmatic. In the upper limbs the only muscles not para- lysed were the flexors of the elbow. The limbs at first lay ex- tended and close to the body, but when told to try to move them, the patient bent the elbows so as to bring the hands up to the shoulders. The pupils were slightly contracted. An attempt was at once made to reduce the dislocation by INJURIES TO THE CERVICAL REGION. 17 extension, followed by flexion, of the neck, and a distinct jerking was felt by the assistants who were steadying the trunk. The patient expressed himself as feeling his pain relieved, but no other change was produced. Later, another attempt at reduction was made under chloroform, but with equally little success. The patient was now put to bed, the head being steadied by pillows and sandbags. At this time the temperature was below 95, and the skin felt cold ; the pulse was strong and regular ; the penis was turgid, the urine retained. About 4 A.M. on the following day the temperature began to rise rapidly ; the skin was hot, flushed, and perspiring ; and the patient became delirious. At 6 A.M. the temperature had risen to 106.6, at 8 A.M. to 108, and at 9.30 to no , at which time the man died comatose. There was no post-mortem examination. For notes of the above I am indebted to Mr. Stocks, the house-surgeon. This case is also somewhat unsatisfactory, as the accident happened on Saturday night, and the man died on the Sunday morning, so that it was not very fully observed. It indicates the high position of the nucleus for the flexors of the elbow, and shows that the deltoid and supinators, also supplied by the fifth root, were paralysed. Thus, then, as in Case 3, we are led to place the deltoid nucleus below that of the flexors of the elbow. Hence we find that of the four motor nuclei comprising the " fifth root group," the lowest is that for the supinator longus (and brevis ?), paralysed in Oases 4 and 6 ; and that next to this comes that for the deltoid, paralysed throughout in Case 7, and as a result of ascending myelitis in Case 3. Thus the flexors of the elbow would appear to occupy the highest position of the segment a result which, although it appeared to me improbable, I cannot but accept on the evidence of these and other cases, such as the following, in which again the flexors of the elbow were alone spared in the left upper limb. CASE 8. Fracture of fifth cervical vertebra Paralysis below biceps nucleus on right side andpronator nucleus on left Trephining Death, R. R., aged thirty-three, was admitted to the Manchester In- firmary, under the care of Mr. Hardie, on November 21, 1888. B 15 SURGERY OF THE SPINAL CORD. Four days previously lie liad been struck on the back of the neck by a weight, which he estimated at 3 cwt., and which was hanging from a chain. The head was forced forwards on to the chest. He did not lose consciousness, nor present any signs of cerebral concussion or other head-injury, but he became imme- diately paralysed. Subsequently to the time of the accident he did not think any change had occurred in his condition. He complained of pain at the back of the neck, but no local deformity could be detected. The lower limbs and trunk were completely paralysed and ansesthetic below the descending branches of the cervical plexus. Respiration was diaphragmatic. The left upper limb lay with the humerus straight by the side, and the forearm across the epigastrium. The only movement which could be effected was flexion of the elbow, which was accom- panied by a readily- felt contraction of the biceps. The right upper extremity had no fixed position, and presented a greater range of movement, flexion of the elbow and abduction of the humerus being readily performed, while there was slight power of adducting the humerus, and of supinating and pronating the wrist. Sensation was much better on the outer border of the left upper limb than in any other portion of it, and was almost entirely lost on the inner aspect, but there was no defined limit ; the hand was completely anaesthetic except along its outer border and over the root of the thumb. In the right upper limb the limits of sensa- tion were similar, but the anaesthesia was less complete. The plantar and crernasteric reflexes and the knee-jerks were absent. Both palpebral fissures and pupils were small, and the latter did not dilate on pinching the skin of the neck. The urine, which was retained, was neutral (sp. gr. 1023), and contained no sugar, albumin, or other abnormal constituent. The temperature was 99.6. The penis presented no turgidity. The pulse was 96, small and soft. The skin felt dry and warm, and presented several superficial suppurating sores on the feet, thighs, and abdomen, the former due doubtless to the use of hot bottles, the latter admittedly the result of turpentine stupes. On November 22, five days after the injury, Mr. Hardie pro- ceeded to trephine the spine. The back of the neck having been shaved, and the patient lying on his face, with the head over the end of the table, and supported by an assistant, a median incision was made over the cervical spinous processes, and carried down to the bones. The soft structures were reflected to either side, partly by the knife and partly by the raspatory. Haemorrhage INJURIES TO THE CERVICAL REGION. 19 gave a little trouble, but was soon checked by the pressure of sponges. On exposing the vertebral arches, the fifth cervical spinous process was found to be loose, and after some trouble it was wrenched away in one piece with the left lamina. When this fragment of bone had been taken away, the dura mater was partly exposed, and the right lamina of the sixth cervical arch was also found to be fractured. With a Key's saw, supplemented by the bone-forceps, the left lamina of this arch was divided, and the posterior portion of the arch thus entirely removed. The exposed dura mater appeared perfectly normal, and was now obviously free from compression at any point. A large drainage- tube was therefore placed in the wound, which was sutured and dressed with iodoform and wood-wool pads. The spray was used throughout. During the operation respiration ceased, and the patient's condition became very critical, requiring him to be turned on to his back for a time, with the use of artificial respira- tion and inhalation of nitrite of amyl. No improvement followed the operation, and very shortly after recovery from the chloroform the patient passed into gradually deepening coma. The tem- perature rose to 101 on the evening of the day of opera- tion, and reached 103.8 the following morning. It then again fell rapidly to 99.4 in the evening, and to 98 on the second day, when the patient died comatose and cyanotic. He thus survived the operation by forty-eight hours. At the post-mortem I re- moved only the affected region of the spine, the condition of which is fully explained by the accompanying illustration (fig. 4), taken from a sagittal section previous to removal of the cord. The body of the fifth Cervical Vertebra is Fig. 4. Section of second to seventh cervical verte- 1 , i , -, -. bra, the arches of the fifth and sixth being Completely Smashed, and pro- removed, and the body of the fifth fractured. jects backwards, distinctly compressing the cord. The mem- branes were uninjured. 2O SURGERY OF THE SPINAL CORD. The right upper limb of this patient had suffered less severely that the left, and it is obvious that some of the muscles supplied by the sixth cervical root had escaped paralysis. We shall refer to this root more fully directly, but may note in passing that the muscles here spared were the adductors of the humerus and pro- nators of the wrist, a condition corresponding with the high position given to their nuclei in our Table. The following is another instance of an oblique lesion of the cord, including in the damaged area the origin of the sixth cervical root on the left side, and extending upwards on the right so as to involve that of the fourth and fifth roots. The reason of this obliquity was not noted at the post-mortem examination, but it was probably due to a higher extension of the central hasmorrhage on the right side of the grey substance of the cord. CASE 9. Dislocation of fifth cervical vertebra Complete paralysis of right upper linib ; paralysis lelow fifth root nuclei on left Trephining Death. J. C., a labourer, aged thirty-eight, was admitted to the Manchester Royal Infirmary, under the care of Mr. Hardie, on October 25, 1887. On the afternoon of this day he had fallen from a waggon for a distance of about six feet, striking the back of his shoulders and head. He was immediately paralysed, but did not lose consciousness. I did not see him until the following day, but am informed by the house-surgeon that his condition on admission was the same as when he came under observation. On October 26 he had pain across the shoulders, shooting down the arms to the elbows, but no tenderness of the spine or pain on pressing down the head. There was some arching back- wards of the cervical vertebrae, but no lateral deviation, and no obvious deformity of the spinous processes. The lower limbs were absolutely paralysed, as were the abdomen and thorax, respiration being diaphragmatic, jerky, 1 8 per minute, with subjective sense of dyspnoea and cough. The left upper limb was abducted at the shoulder, with the elbow flexed and the hand across the chest ; the right was completely flaccid. On the left side the patient retained the power of voluntary contraction of the supra- and infra-spinati, biceps, deltoid, and supinator longus, but not of the other limb-muscles, whereas on the right side all the muscles were paralysed. The neck-muscles were INJURIES TO THE CERVICAL REGION. 21 normal on both sides. Both palpebral fissures and pupils were smaller than usual, but not so markedly so as in many cases. Anaesthesia extended as high as the level of the third ribs in front and the sixth cervical spine behind, but on the right side sensation was retained over the region of the deltoid and slightly beyond it, and on the left side it extended over the area of the deltoid, and thence down the outer side of the limb to about the root of the thumb, becoming, however, very vague at the lower part. The anaesthetic boundary was not very sharply marked, and had no adjoining hyperaesthesia. The knee-jerk and plantar, cremasteric, gluteal, and epigastric reflexes were absent. The skin felt dry and warm, although the temperature was normal. Urine was retained. The penis was turgid, but less so than on the previous day. Pulse 66, feeble, and with a very marked respiratory wave, being full and soft towards the end of inspiration, and very small towards the end of expiration. The man's condition being clearly otherwise hopeless, Mr. Hardie determined, after consultation with several of his col- leagues, to trephine the spine, which was done at 4.20 P.M. on the afternoon of the day after admission, about twenty-four hours after the injury. For the subsequent notes I am indebted to Mr. Bannister, the house surgeon. Chloroform having been administered, a vertical incision about four inches long was made over the cervical spinous processes, having its centre opposite the fifth. The muscles being cleared from the laminae, an interval of about a quarter of an inch was found between the fifth and sixth spines, and the fifth vertebra appeared to be slightly displaced forwards. The laminae of the fifth and sixth vertebras were now removed by bone-forceps, when the dura mater was exposed, presenting a perfectly normal ap- pearance without any trace of haemorrhage. As nothing further could be done, the dura was not opened, but the muscles were brought together by deep catgut sutures, a large drainage tube inserted, and the wound closed over a smaller superficial drain. The carbolic spray was used throughout, and wood-wool pads used as a dressing. After the operation brandy was given at frequent intervals. At 6 P.M. the pulse was 54 and feeble; temperature 96; respirations 13, and still purely abdominal. At 10 P.M. pulse 74; temperature 98.6, respirations 16. The patient passed a fairly good night, but in the morning the temperature was 103.4. On the afternoon of the 2/th he became suddenly much worse; 22 SURGERY OF THE SPINAL CORD. the respirations became very feeble and then stopped ; the heart- beats, which were very feeble and infrequent, continuing for about ten minutes longer. A few minutes after death the temperature in the mouth was 104. The post-mortem examination was made by Dr. Harris. The disc between the fifth and sixth cervical vertebrae was found to be ruptured, the former bone projecting very slightly forwards. No fracture was discovered. The dura mater was uninjured, but the cord was flattened opposite the seat of injury, and was much contused for about an inch above and below, containing haemor- rhages in its substance and in the central canal ; elsewhere its structure was normal. The first and second bones of the sternum were also partially separated, and the lungs much congested. Having thus illustrated the functions of the fifth cervical root, we may now pass to the consideration of cases in which the lesion is situated at a lower level. CASE 10. Fracture-dislocation of fifth cervical vertebra Partial destruction of brachial region of cord Death. J. E. C., aged thirty-three, was admitted into Mr. Heath's wards on March 25, 1887, at 2.30 P.M. He had shortly before been " larking " with some friends, and had another man seated upon his shoulders, when he was pushed in the face backwards against a high counter. The result was that his neck was twisted backwards, the man falling from his shoulders. For the first few minutes he only noticed pain in the back of the neck, but then his legs began to feel weak, and he lay down : within ten minutes the lower limbs were completely paralysed and insensitive, and he found that he could not straighten the left forearm. When admitted, there was paralysis of the lower limbs, and the left upper limb was only partially movable, being flexed at the elbow and somewhat abducted at the shoulder. The right limb appeared to retain more power. The temperature at 4 P.M. was 94.2, at 8 P.M. 97.6, and at midnight 99.2, near which point it remained for some days. He was placed in a water-bed, and the urine withdrawn by the catheter. On the following morning he complained of pain in the back of the neck, but there was no local deformity, and no pain on pressing down the head. The lower limbs were absolutely para- INJURIES TO THE CERVICAL REGION. 23 lysed, as were the abdominal and thoracic muscles, respiration being diaphragmatic. The left upper limb lay with the fingers partially flexed, the wrist straight, hand prone, elbow flexed, and the humerus abducted to an angle of about 45 with the body: he often raised the humerus above the shoulder, otherwise retaining the same position, except that the wrist became semi-prone. He could not extend the elbow, nor flex nor extend the fingers, but on attempting to flex the fingers there was slight extension of the wrist ; he had also slight power of flexion and extension of the wrist, but this move- ment was extremely limited : pronation and supination were fairly good : the pectoralis major, latissimus dorsi, and apparently the subscapularis contracted very feebly ; the biceps, deltoid, and supinator longus were but little if at all impaired. On the right side the condition was practically the same, except that there was rather more power in the wrist. On taking a deep breath, the sterno-mastoid, trapezius, and levator anguli scapula3 contracted very distinctly on both sides. As regards sensation, there was a subjective " feeling of heat " in the left palm and forearm. Anesthesia was nowhere complete, but was almost so below the level of the third ribs, and in the upper limbs internally to a plane running down the centre of the arms and forearms to the styloid processes of the ulnas, both before and behind. Below these limits there was absolute analgesia, but a vague sensation was conveyed by tickling. The limit was very ill-defined, and above it was an indistinct hyperassthetic zone. There were no superficial reflexes nor tendon reactions. Urine was retained, and had to be drawn off by the catheter ; its sp. gr. was 1024 ; it was neutral, and contained neither sugar, albumin, nor any deposit. The bowels had not been moved since admission. The respirations were at the rate of 19 per minute, with no sense of dyspnoea, but slight cyanosis. Pulse 69, full and soft. Skin dry and warm. The penis was turgid. Both palpebral fissures and pupils were small, and there was no dilatation of the pupils on pinching the neck. Two days later, the paralysis of the upper limbs was of equal extent on both sides. There was complete loss of power in all the intrinsic and extrinsic muscles except the biceps, deltoid, supinators, and subscapularis, the elbows being flexed, the humeri abducted but not rotated outwards, and the hands thus lying across the chest. The pectoralis major, latissimus dorsi, and teres major had become quite flaccid. The region of anesthesia in the upper limbs had also extended. The temperature was normal. The 24 SURGERY OF THE SPINAL CORD. optic discs were examined, but presented no abnormality. Pria- pism was less marked. On the fourth day the urine contained a little pus (and there- fore albumin), but no sugar. Its reaction was acid. On the fifth day the optic discs appeared less well defined than before, and presented some venous congestion. On the sixth day the subscapularis and supinator longns could no longer be felt to contract, but the arms usually occupied the same position as before, although during sleep they were often raised above the shoulder. He complained much of a sense of pain and stiffness in the upper limbs. The optic discs were more vascular, and were hazy an observation which was confirmed by Dr. Little, who held, however, that there was no neuritis. For a few days sensation in the trunk and lower limbs now seemed to improve slightly, but the patient became weaker, and was frequently somewhat delirious at night. The temperature ranged from IOO to IOI. On the eleventh day were noted tremors of the paralysed muscles of the upper limbs. A day later, the deltoid and biceps of the left side were found to be beginning to fail, and the humerus was less abducted than formerly. At the same time sensation began to fail again. On the fourteenth day the left upper limb was absolutely paralysed and anaesthetic, the humerus lying by the side, the elbow at a right angle. On the right side, the only muscle whose contraction could be felt was the deltoid. Ecchymoses had formed on the heels, toes, and malleoli. On the fifteenth day a distinct knee-jerk could be obtained on the right side, and on the left a slight reaction was present. A few days later he developed symptoms of pneumonia, and the condition of the urine became much worse. The temperature, which had regained the normal on the fifteenth day, again began to rise on the twenty-third, keeping a fairly steady upward curve until the twenty-ninth day, when it reached 104.6, and death ensued. During the later period there was obviously more rapid wasting in the forearms and hands than in other parts of the body. On several occasions also it was noted that the passage of the catheter was accompanied by reflex contractions of the sartorii. At the post-mortem examination I found some separation of the fifth and sixth cervical spinous processes. The body of the fifth was partially dislocated forward, forming a very obtuse angle with that of the sixth, and overlapping the latter anteriorly by INJURIES TO THE CERVICAL REGION. 25 about a line. The articular processes were in contact, but were partially slipped off one another. The upper and anterior margin of the body of the sixth vertebra was very slightly ground off, but there was no other fracture. The vertebral canal contained a little dark clotted blood at the seat of the lesion. The cord was here partially compressed and very pale, all distinction of white and grey matter being lost. This condition extended only for about an inch, and elsewhere the cord presented no macro- scopic abnormality. No nerve-roots were crushed. There were marked cystitis and double pneumonia. We have here another case in which, after the cord had been crushed below the fifth cervical nerve-roots, the muscles supplied by these escaped paralysis for a considerable time. The case differs, however, from those previously mentioned, in that the annihilation of the functions of the cord below the lesion was less complete, as evidenced by the fact that anaesthesia was not absolute, and that some power remained in many of the muscles supplied by nerve-roots distinctly below the lesion. The examina- tion on the second day showed that whereas the flexors of the elbow, deltoid, and supinators retained a very fair amount of power, the other muscles of the limb were paralysed to a varying extent. Thus, next to the " fifth root group " in order of power we find the subscapularis, pronators, pectoralis major, and latissimus dorsi, between which no distinction could be drawn, and we find also that the extensors of the wrist still retained a little power. On the fourth day we have paralysis of all the muscles supplied by the brachial plexus, except the "fifth root group " and the sub- scapularis, the retained tonus of the latter preventing such out- ward rotation of the humerus as is seen in fig. I . Again, on the sixth day the subscapularis and supinators fail, and later the del- toid and biceps begin to do so. As there can be little doubt that myelitis was extending upwards, we may then accept as indi- cating the arrangements of their nuclei from below upwards the order in which the muscles here lost their power, viz. : 1. Intrinsic muscles of the hand and flexors of the wrist and fingers immediately completely paralysed. 2. Extensors of wrist almost absolutely paralysed on second day. 3. Pectoralis major, latissimus dorsi, teres major, and pronators following before fourth day. 4. Subscapularis retaining power longer than any muscles but those of the fifth root. 26 SURGERY OF THE SPINAL CORD. The high position of the subscapularis is partially confiraied by Case 8, already referred to ; and in the latter we find evidence that the pronators are supplied from a neighbouring point. Thus, although several muscles have not yet been localised, the arrange- ment of our Table is so far perfectly illustrated. CASE 1 1. Diastasis in cervical region Partial paralysis Trephining Death. (Axillary 97-2) Dec. 22. Front of thigh 87.8 Front of upper arm 88.8 (Axillary 98) Dec. 23. Front of thigh (an hour after using battery) . 91.6 Front of upper arm ...... 86.7 j (Axillary ........ 97.6) Dec. 27. Front of thigh (before using battery) . . . 84.9^ Front of thigh (immediately after using battery) . 83. 6 j- - 4. 5 Front of upper arm . . . . . . 89. 4 J (Axillary 97) Jan. 8. Front of thigh (before using battery) . . . 86.4 Front of thigh (immediately after battery) . . 83.9 Front of upper arm 90 (Axillary ........ 97.4) -3-6 During his stay in hospital this patient never presented any changes of importance. His axillary temperature was through- out slightly subnormal. One other point is worthy of notice ; his optic discs were carefully examined on several occasions, but re- vealed no abnormality. The treatment consisted in faradisation of the lower limbs, and washing out the bladder daily with a solution of boracic acid. On February 2, 1889, he was discharged as incurable. CASE 27. Fracture-dislocation of tenth dorsal vertebra. L. J., a collier, aged thirty, was admitted on December 8, 1888, to Mr. Whitehead's wards. Shortly before admission he had been at work in a coal-pit, when a mass of rock, weighing nine or ten cwts., fell, so that a part of it struck him in the " middle of his back." He immediately sank down quite helpless. On admission, he presented some swelling about the eleventh dorsal vertebra, and the lumbar concavity appeared to begin too soon. On the following day, extension was made, under chloro- form, by jack-towels round the waist and thighs, the spine being manipulated at the same time, and the deformity was said to have been thereby reduced. I saw him for the first time on December 1 1 . He had then INJURIES TO THE DORSAL REGION. 73 prominence of the eleventh dorsal spine, with a depression above it, and some swelling in the lumbar region. Crepitus could not be obtained. Any movement of the lower limbs caused much pain, but no pain resulted from jarring the spine vertically. The lower limbs were absolutely paralysed, the trunk and upper limbs being normal. The plantar and cremasteric reflexes and the knee-jerk could not be elicited. Below the limits of the distribution of the eleventh dorsal nerve there was partial anaesthesia ; but vague sensation extended rather more than a hand's-breadth beneath this point, complete anaes- thesia only beginning a little below Poupart's ligament. The penis and scrotum were anaesthetic, and the passage of a catheter was not felt until the moment of its entrance into the bladder. The urine had been retained and the bowels unopened since the acci- dent. The penis presented no turgidity. The skin of the lower limbs felt dry and cool. The surface temperatures were as follows : Difference in favour of lower limb. Dec. 21. Front of thigh ....... 91 ) j, Front of upper arm ...... 91.8 ) (Axillary temperature . ..... 99.4) Dec. 24. Front of thigh ....... 92 , Front of upper arm ...... 90 (Axillary temperature. ..... 97.6) Jan. 1 6. Front of thigh ....... 86.2 Front of upper arm ...... 87.8 (Axillary temperature ...... 98.6) Apr. 16. Front of thigh ....... 93.2 Front of arm ....... 94.8 (Axillary ....... . 99.4) The bowels continued to be very constipated, and cystitis shortly supervened, for which the bladder was daily washed out with boracic acid lotion. On February i, 1889, his condition was again carefully examined. The lower limbs were much wasted, and still com- pletely paralysed and anaesthetic. The plantar and cremasteric reflexes and the knee-jerks could not be obtained. The upper boundary of the anaesthesia corresponded accurately to the lower limit of the distribution of the last dorsal nerve. After washing out and emptying the bladder, urine was retained for some two hours, after which incontinence came on, remaining until the bladder was again emptied on the following day. This incon- tinence consisted in a continuous dribbling with an occasional forcible and copious discharge. Even when the bladder was full, 74 SURGERY OF THE SPINAL CORD. no dulness could be obtained on percussion above the pubes. The patient was conscious of the distension of his bladder by the lotion. The urine itself remained very foul and purulent. The temperature was irregular, being frequently above normal. Bed- sores had formed on the left buttock and on both knees and heels. Scratching of the skin of the thighs, which was very dry, caused marked hyperasmic lines, lasting for some minutes. The fundi of the eyes were normal. On April 16, 1889, when the last note was taken, the man's condition was practically unchanged. The lower limbs had wasted greatly, and were rigid and extended, with the toes pointed. The skin was rough and dry, with ulcers at various places. The super- ficial and deep reflexes were still absent below the injured region. The bladder had gradually acquired the power of retaining urine for a longer period, amounting to about four hours after catheter- isation, and the urine was less foul and contained less pus. CASE 28. Dislocation of eleventh dorsal vertebra. J. R., a collier, aged twenty-two, was admitted under Mr. Jones's care on July 19, 1888. A week previously he had been working in a mine, when some coal fell upon his head, throwing him" forwards, after which a further quantity of coal came down on to his back. He did not lose consciousness or present any signs of cerebral concussion, but found at once that he could not move his legs. On admission, he complained of pain in the lumbar region of the spine, and there was found a diffuse prominence, most marked over the last dorsal spine, but obscured by effusion of blood, which extended somewhat higher than this point. No pain was caused by vertical jarring of the spine. The lower limbs were completely paralysed, but the abdominal, thoracic, and upper limb muscles were unaffected. The plantar, cremasteric, abdominal, and epigastric reflexes were all absent, as was the knee-jerk. Anaesthesia had a well-defined border, corresponding accurately throughout to the lower limit of the distribution of the last dorsal nerve, and there was no hyperaasthesia ; those branches of the last dorsal nerve which descend on to the upper part of the gluteal region retained their sensation, but the rest of this area was anaesthetic. The urine was retained, fulness of the bladder causing pain, and the urine contained pus and phosphates (the patient had INJURIES TO THE DORSAL REGION. 75 previously been suffering from gonorrhoea) ; but no sugar and very little albumin. The bowels were very constipated. On the feet were patches of redness, and the skin about the perineum and penis was red and rather raw. The penis itself was turgid. The slightest scratch of the lower limbs produced a bright hyper- asmic line, lasting for several minutes. The temperature was normal. Treatment consisted in periodic evacuation and washing out of the bladder. Two days later the patient was put under chloroform, and an attempt made to reduce the spinal dislocation. Jack-towels being placed round the thighs, the thorax was firmly held, and extension made upon the lower limbs, when a distinct jerk was felt at the site of the fracture, the prominence of the twelfth dorsal spine becoming less marked. On relaxing the extension, the deformity returned as before, and the process was repeated two or three times, the pelvis being also carried backwards so as to increase the deficient lumbar convexity. Permanent reduction was, how- ever, found to be impossible, and a, plaster of Paris jacket was then applied, the back being partially supported by a towel under the lumbar region until the plaster had set. On July 31, there being no improvement, the jacket was removed with the view of trephining the spine ; but there being now no deformity, the operation was not performed, and a felt jacket was reapplied. From this point the case presents little of interest. The nervous symptoms did not improve, the only change being that in September the patient complained a few times of shooting pains in the lower limbs. When the jacket was removed six weeks after its reapplication, the twelfth dorsal spine was as prominent as ever, having a depression above it. Turgidity of the penis passed off a few days after admission. The urine con- tinued to be very foul, purulent, and ammoniacal, and on one occasion a phosphatic concretion about the size of a hemp-seed came away in the eye of the catheter. Gradual emaciation ensued, and on October 25, 1888, the man was sent home as incurable. The first point to be noticed is that in these, as in other pub- lished cases of spinal injuries, the level of the upper border of the anaesthesia is usually somewhat below the level of the lesion. Then, in Case 23, where, from the prominence of the sixth dorsal spine, we probably had a dislocation forwards of the fifth dorsal 70 SURGERY OF THE SPINAL CORD. vertebra, the anaesthesia only affected the intercostal nerves as high as the sixth (inclusive), and in Case 24, although the sixth dorsal vertebra was displaced backwards and divided the cord, the anaesthesia did not extend above the eighth intercostal nerve. Similarly, it will be found throughout that the upper level of the anaesthesia is generally somewhat below the area of distribu- tion of the nerve trunk corresponding to the injured vertebra, the only exception being Case 25. But as it is practically not possible to differentiate the action of each intercostal muscle, we can only assume that the paralysis probably reaches to the same level as the anaesthesia, and thus we conclude that the superior limit of the isolation of the spinal nervous system 13 generally rather lower than might at the first glance be expected. This relationship is best represented by a table giving the pro- bable level of the crush of the cord, and the actual upper limit of paralysis and anaesthesia. The probable level of the lesion is, in the absence of post-mortem data, derived from the marked prominence of a spinous process, such prominence being taken to indicate a dislocation forwards of the body of the vertebra imme- diately above that of which the spine projects. We thus obtain the following results : l PROBABLE SITE OF LESION RELATIVELY HIGHEST NERVE WHOSE FUNCTIONS CASE TO THE VERTEBRA. ARE LOST. 23. Junction of fifth and sixth dorsal. . . Sixth intercostal. 24. Sixth dorsal Eighth intercostal. 25. Seventh dorsal Seventh intercostal. 26. Junction of ninth and tenth dorsal. . . Twelfth dorsal. 27. Junction of tenth and eleventh dorsal. . . First lumbar. 28. Junction of eleventh and twelfth dorsal. . First lumbar. In order further to ascertain this relationship, I have taken from Gurlt's analysis 2 all those fatal cases of fracture in the dorsal region in which there is fairly definite information as to the exact site of the injury and the upper level of the paralysis and anaesthesia. Few of the cases are explicit upon this point, but these few I have arranged in a Table. The first column shows the probable exact site (relatively to the vertebrae) of the crush of the spinal cord ; the second gives the level to which symptoms are said to have extended ; and the third, the nerve which would from this datum appear to have been the highest to be affected. 1 Case 22 is omitted, as the symptoms were too indefinite for accurate localisation. 2 Uandbuch der Lehre von den Knochcnbrtichen, vol. ii. INJURIES TO THE DORSAL REGION. 77 No. Site of Lesion of Cord Rela- tively to the Vertebne. Highest Level of Paralysis or Anaesthesia. Highest Paralysed Nerve. tl. Second dorsal. Third rib. Third dorsal. 2. Third dorsal. Seventh rib. Seventh dorsal. 3- Third-fourth dorsal. Umbilicus. Eleventh dorsal. +4- Fourth dorsal. Sixth dorsal vertebra. Sixth dorsal. +5- Fourth-fifth dorsal. Epigastrium. Sixth or seventh dorsal. t6. Fourth dorsal. Epigastrium. Sixth or seventh dorsal. t7- Fifth-sixth dorsal. " As far as the false ribs." Seventh dorsal. *8. Fourth-seventh dorsal. Nipples. Fourth dorsal. t9- Sixth dorsal. Two inches above umbilicus. Eighth or ninth dorsal. tio. Seventh dorsal. Umbilicus and eighth dorsal Eighth or eleventh vertebra. dorsal (?). tit. Seventh-eighth dorsal. Pit of stomach. Ninth dorsal (?). tl2. Eighth dorsal. Three fingers' breadth above Ninth dorsal. umbilicus. *i3- Ninth dorsal. Two inches above umbilicus Ninth dorsal. and twelfth rib. ti 4 - Ninth-tenth dorsal. One inch above umbilicus. Tenth dorsal. t.5- Ninth-tenth dorsal. Umbilicus. Eleventh dorsal. 1 6. Ninth-tenth dorsal. Four inches above umbilicus. Eighth dorsal. t!7. Upper eleventh dorsal. Half inch below umbilicus. Twelfth dorsal. ti8. Whole eleventh dorsal. Last false rib. Twelfth dorsal. *ig. Middle eleventh dorsal. Umbilicus. Eleventh dorsal. *2O. Eleventh-twelfth dor- Umbilicus. Eleventh dorsal. sal. t2I. Twelfth dorsal. Anterior superior spine of ilium. Second lumbar. t22. Middle twelfth dorsal. A nterior superior spine of ilium. Second lumbar. 23- Twelfth dorsal. Paralysis of lower limbs, anaes- Motor, second lum- thesia below knees. bar sensory, fifth lumbar. t24. Twelfth dorsal. Paralysis and anaesthesia of Second lumbar. lower limbs. 25- Eleventh-twelfth dorsal. No paralysis, anaesthesia of Fifth lumbar. sciatic nerves. 26. Eleventh dorsal to first Paralysis of lower limbs, anaes- Fourth lumbar (?). lumbar. thesia from middle of thigh and gluteal fold. 27. Twelfth dorsal. Inguinal region. Third lumbar (?). Looking now at the above Table, we find that the cases can be arranged in three groups, viz. : Group A. (marked *) consists of four cases (8, 13, 19, and 20), in which the nervous symptoms extend as high as the vertebral lesion. To these may be added No. 25 of my own cases, giving five instances out of thirty-three. Group B. (marked t) consists of sixteen cases, in which the nervous phenomena find their highest level at a distance, generally equal to the area of distribution of about two inter- costal nerves, below the trunk coming out under the displaced vertebra. Adding to these five of my own cases, we find in this group twenty-one out of thirty-three cases. 78 SURGERY OF THE SPINAL CORD. Group C. (Cases 2, 3, 23, 25, 26, 27, and 16 from Gurlt) contains the remaining seven cases, in the first six of which the paralysis was a considerable distance below the vertebral lesion, whereas in the last it extended above this level. The reason of this distribution will be obvious upon looking at the diagram given by Dr. Gowers in his work on " The Diag- nosis of the Diseases of the Spinal Cord." If we have a dis- location, say, between the fourth and fifth dorsal vertebrae, we have a crush of the spinal cord about the level of origin of the sixth dorsal nerve, with possible injury to the fourth and fifth roots, which here lie beside the cord. But the cord is a much more fragile structure than the roots, and is from its size and position more exposed to injury, so that it is constantly damaged in cases in which the roots remain intact. Hence we must expect the level of the paralysis to be lower than that of the vertebral lesion by just so much distance as is occupied by the intraspinal course of the nerve-roots at the site of injury. In this way we can explain the distribution of the symptoms in the large number of cases forming Group B. In doing so, it must be remembered that the level of origin of the nerve-roots rela- tively to the vertebrae varies within considerable limits, extend- ing even, it may be, to more than the depth of an entire vertebra, a point clearly illustrated by Mr. Reid's excellent diagram. 1 Should the crush be very severe, we may also have the roots injured, when we get the exceptional condition of Group A. Thus, in my own Case 25, which was of this nature, the spinal injury was so severe that " the spine was movable in all direc- tions;" and in Case 1 6 of those quoted from Gurlt, we are distinctly told that the roots of the ninth and tenth nerves were destroyed. In Group C. are two cases (2 and 3) which I find unintelli- gible. In both, the cord was said to be torn across at the site of the fracture, and in the second of them the ends were sepa- rated by more than an inch. Under these circumstances, we can hardly accept as reliable the statements that anaesthesia only commenced far below the level of the lesion. Cases 23, 25, 26, and 27 really belong to the same category as those of Group B. ; they are all injuries about the twelfth dorsal vertebra, to which correspond the origins of the second and subsequent lumbar \ nerves and the commencement of the cauda equina, and the apparently very low boundary of the anaesthesia is a result of the long intraspinal course of the nerves in this region. To sum up, we find that, omitting the two doubtful cases and 1 Journal of Anatomy and Physiology, 1889, vol. xxiii. p. 341. INJURIES TO THE DORSAL REGION. 79 Case 1 6, which will be referred to presently, we have thirty injuries in the dorsal region, in five of which both the cord and the roots were crushed, so that the level of the paralysis and anaesthesia corresponded to that of the bony lesion ; whereas in twenty-five cases, the cord only being crushed, the limit of the nervous symptoms lay correspondingly lower. The point may appear a trivial one, but it has really a most important practical bearing in at least two directions. 1. There seems a strong probability that the operation of " trephining " the spine may shortly become not infrequent, if not for injuries, at any rate for certain other pressure lesions of the cord. It is thus of the first consequence to recognise and to recollect that the seat of compression will, in the great majority of cases, be higher than that of the anaesthesia by the length of the intra-vertebral course of the implicated nerves. In his exhaustive paper upon the surgery of tumours of the spinal cord, 1 Mr. Victor Horsley refers in some detail to this subject, and comes to the conclusion that " the difference between the position of the growth and the localisation of the pain is clearly due to the anatomical relations of the nerve organs and roots to the vertebrae, and something more, viz., the as yet (in the human being) imperfectly known course of the fibres in the spinal cord." So far as spinal injuries throw any light upon the subject, there does not, however, appear to be any necessity, in the cases composing Group B., to assume any other factor in the determination of the level of the lesion than the obvious ana- tomical conditions already referred to, varying as Reid has shown these conditions to be. 2. Another important practical point which is brought out by the above facts is that where (as in cases of injury) the site of the lesion relatively to the spine is already known, and where the anaesthesia extends as high as this level, then we are in the pre- sence of a lesion sufficiently severe to have compressed both the cord and its roots, one, therefore, in which any operation will probably be utterly hopeless. There remain for consideration a few cases in which the upper limit of the anaesthesia is found to be considerably below that of the lesion much lower than can be accounted for by the intra- vertebral course of the nerves. Two cases of this nature have been recorded above on pp. 26 and 47, and these two cases probably provide the explanation of the phenomenon. In one of them (Case 1 6) we had a central haemorrhage in the lower cervical 1 Med. Cbir. Trans., vol. Ixxi. p. 413. ^/ A- 8o SQRGEEY OF THE SPINAL CORD. region, and the complete anaesthesia, which was transient merely, only extended as high as the knees, thence shading gradually to " as high as a line drawn round the abdomen about two inches below the umbilicus." This being one of my earlier cases, I am by no means certain that the expression " as high as the knees " correctly represents the limits of the anaesthetic region, which probably extended much higher on the posterior aspect of the limbs (infra, pp. 126, &c.) ; but the important points are that the upper level was far below that of the lesion, and that the boundary was very ill-defined. Again, in Case 1 1, we find that the lesion was situated about the point of origin of the sixth cervical nerves, but that complete anaesthesia extended only as high as the sixth dorsal nerves ; and that again the boundary was a very ill-defined one, some impairment of sensation extending upwards to the lower cervical nerves. In both cases there was ample evidence that the functions of the cord were not entirely destroyed by the lesion, and that some of its conducting fibres had escaped complete compression. But in the first case, it is certain that^the lesion was a central haemorrhage ; and in the second, there was no persistent bony displacement, so that haemorrhage was the sole cause of symptoms, and haemorrhage is always most severe in the centre of the, cord. It will therefore follow that in both cases the morel peripheral of the descending fibres would be less subject to com-/ pression than those more centrally situated ; and if the sensory fibres for the lower parts of the body be the more centrally situated, these would chiefly suffer. It would appear that this is the case, and that in these two instances the eccentric pressure was in- sufficient to paralyse the most peripheral fibres that is, those which leave the cord highest. This view will explain the very gradual increase in the anaesthesia from above downwards, and the suggested arrangement is also obviously probable, inasmuch as, if the higher fibres were situated centrally to those which leave the cord below them, they would require to cross the latter in order to reach their point of exit. Such an explanation appeared to me adequate to explain the phenomena, until I became aware, from reading Mr. Horsley's paper above referred to, that the same tendency to implicate the lowest sensory nerves first is observed also in the case of tumours whose pressure upon the cord is concentric, and which would therefore, in accordance with the above theory, appear likely to produce at first an exactly opposite condition. In the absence of any other explanation, however, I am still inclined INJURIES TO THE DORSAL REGION. 8 1 to regard the theory as probably correct. The central parts of the cord are the most vascular, and the nerve-fibres are here least protected by the intramedullary connective tissue, so that even in the case of a concentric pressure lesion, we can under- stand that they may be the most susceptible both to the direct effects of pressure and to the indirect results of any localised congestion which may be, and probably is, created thereby, Mr. Horsley also calls attention to the fact that, in the case of tumours, the direction of invasion of paralysis is the reverse of that of anaesthesia (and pain), being from above downwards. This same tendency is illustrated in some of the above cases, especially in Case 21 (p. 5 9), in which, during recovery from a lesion external to the cord, power of voluntary movement was partially restored in the lower limbs first, beginning at the ankle, and in the case of the upper limbs the paralysis improved in the hands only. So also the majority of the cases of hsematomyelia pre- sent, during recovery, a return of power from below upwards. Possibly, therefore, the motor fibres are laterally arranged in a manner exactly opposite to that of those for sensory conduction, but the present evidence upon this point is even more scanty in the case of the former than in that of the latter. Finally, it will be obvious that if, in a case of fracture of the spine, either myelitis or haemorrhage extend above the level of the bony lesion, the nerve-symptoms will also extend to a corre- sponding degree, a condition illustrated by Nos. 13 and 14 of my own cases, and by No. 1 6 of those quoted from Gurlt. The above records of the surface temperatures in the paralysed and non-paralysed regions respectively are too few in number for safe generalisation, and they are here introduced mainly as afford- ing material which may be useful in assisting future research, it being only by collective investigation that we can obtain satis- factory conclusions upon such a point in cases of such comparative infrequency as spinal injuries. It would, however, appear that, in a complete transverse injury of the cord, we have produced, even from an early period, some contraction of the vessels of the paralysed regions at least this is so where the injury is below the cervical region. Correspond- ing with the lower temperatures thus observed is the frequently noted dryness of the paralysed limbs, resulting from a deficient secretion of sweat, and giving to the hand a deceptive sensation of warmth. It is even more obvious that when the spinal vaso-motor F 82 SURGERY OF THE SPINAL CORD. centres are left in entire control of the vascular walls, they mani- fest an extreme sensibility to external impressions. Thus it has been constantly observed in the preceding cases, as well as in those which will follow, that slight irritation of para- lysed parts, as by scratching, produces a temporary active con^ gestion of the skin. It would also appear from the results obtained in Cases 22 and 26 that the immediate effect of the application of the electric current is a contraction of the vessels, but that after a lapse of some little time this contraction is followed by a dilatation. I may add that care was taken in all these observations to equalise the conditions of exposure of the parts whose temperature was to be tested, and that neither the uncovering nor the wetting of the skin which accompanied the use of the galvanic battery explains the varying temperatures which resulted. The importance of this abnormal mobility of the blood-vessels, and of their tendency to congestion upon slight irritation, in the causation of " trophic " lesions, is perfectly obvious, and there can be little doubt that similar vascular changes produce important effects on internal organs, as is illustrated by the urinary abnor- malities recorded in Chapter I. the occasional presence of albumin, of blood, of excess of urea, &c., and of a compound capable of rapidly decolourising Fehling's solution. CHAPTER IV. INJURIES TO THE CAUDA EQUINA. ALTHOUGH the subject of the present chapter is but a portion of that to be considered under the head of injuries to the lumbo- sacral region of the spinal cord, it would appear convenient to regard apart a few instances of the commonest result of an incom- plete crush of the cauda equina, and I have therefore reprinted almost verbally a paper which appeared in " Brain " in January 1888, to the subject-matter of which we can refer back in con- sidering other injuries of the lower portion of the spinal cord and its nerve- roots. The series of cases upon which are based the conclusions drawn in the present chapter appear to form a clinical picture the import of which has not hitherto been fully recognised, although its features are sufficiently marked, and the symptoms described have been noted by more than one observer. They present instances of very different lesions, all of which, however, agree in the production of pressure on the cauda equina ; and although they are not all injuries, it has appeared advisable to place, side by side with traumatic cases, those due to other causes, but resembling them in the locality of the lesion and in the nature of the symptoms. I shall, in considering these cases, first relate their clinica. histories, drawing attention to the salient points of each, and shall then proceed to draw certain conclusions, and to compare the facts observed with the experience of previous writers. CASE 29. Dislocation of the, first lumbar vertebra Compression of the cauda equina. P. S. attended as an out-patient in Dr. Ross's clinic during the month of June 1886, and was admitted to the wards on the 8 4 SURGERY OF THE SPINAL CORD. 7th of the following month. He gave a history of having been a heavy smoker and drinker, of an attack of syphilis twelve years ago, and of pneumonia five years ago. On January 31, 1886, he fell from a scaffolding and injured his back. For five days he was unconscious, and he has since then had paralysis of the lower limbs, with retention of urine, requiring the constant use of a catheter. On examination, he presented a distinct deformity of the lumbar spine, there being a wide interval between the first and second spinous processes, with prominence of the latter. There was slight pain in the affected region, but no tenderness. (The exact position of the deformity was verified by repeated examina- tions by various gentlemen.) The lower limbs presented complete paralysis of all the muscles below the knee, and of the flexors of the knee, and there was weakness, but not entire loss of power, in the extensors of that joint. Flexion of the thigh could apparently be performed without difficulty ; the power of adduction was slight, and that of extension and abduction almost, but not quite, entirely lost. The buttocks and lower extremities were wasted throughout. Electric examination of the affected region gave contractions with the following currents : RIGHT LIMB. LEFT LIMB. Kathodal Anodal Farad ic Kathodal Anodal Faradic Closure. Closure. Current. Closure. Closure. Current. Cells. Cells. Cells. Cells. Rectus . ..... No effect No effect Sartorius 35 3 25 2O Vastus externus . :/ i ' " 25 2O 25 30 Vastus interims . , . 35 30 3 30 Gluteus maximus Biceps . . . : No contraction No contraction Semimembranosus with 50 cells. with 50 cells. Semitendinosus . Adductor longus Adductor magnua Gracilis Gastrocnemius . 40 40 35 30 Tibialis anticus . 25 20 2 5 20 Extensor proprius ) pollicis . . | > " Peroneus longus . 25 25 i 30 30 The knee-jerk and plantar reflexes were absent, but the cre- masteric reflexes were normal. Sensation was normal on the upper part of the buttocks, that INJURIES TO THE CAUDA EQUINA. 85 is, in the region supplied by the last dorsal, ilio-hypogastric, and external cutaneous nerves, and was little if at all diminished on the front of the thighs and the anterior halves of their inner and outer aspects, or on the inner sides of the legs ; but there was complete anaesthesia of the backs of the thighs, of that part of the buttocks not included in the above limits, of the outer sides of the legs, and of the feet. The perineum, the penis, and the scrotum were also quite anaesthetic, with the exception of the root of the latter, and the catheter was not felt in the urethra. The patient was, however, aware when the bladder was full, and when he wished to empty the rectum, but had no control over the latter, and could not feel the passage of fseces. At times he would have pricking sensations in the toes and some pain in the thighs. The lower limbs presented no obvious change of temperature. Since the accident there had been no erections of the penis. On both heels were bed-sores of large size. The urine, which was retained, was alkaline, containing large quantities of pus and phosphates. The patient remained under observation and treatment for some time ; but, with the exception of amelioration of his cystitis and bed-sores, underwent no change. On leaving, he was instructed to return, with a view to trephining the spine, but he has not since been heard of. The explanation of the above case is sufficiently obvious. There is sensory paralysis of all the nerves of the sacral plexus, and possibly of the obturator, but not of the anterior crural or other lumbar nerves : the perineum, penis, scrotum, and urethra, being supplied by branches of the pudic, are anaesthetic, but the root of the scrotum retains sensation owing to the presence of twigs of the ilio-inguinal nerve, which, however, only descend to a very short distance. As regards motion, we find complete paralysis with the " reac- tion of degeneration " of the muscles supplied by the nerves of the sacral plexus. Those supplied by the anterior crural, although presenting the reaction of degeneration, are only weakened, and the adductors, supplied by the obturator, appear also to retain some power. Again, the cremasteric reflex remains, but below its level reflex action is lost. 86 SURGERY OF THE SPINAL CORD. CASE 30. Spina bifida Cure Cauda equina compressed ly cicatrix. F. H. W. has been several times admitted into the Manchester Royal Infirmary, under the care successively of Mr. Lund, Mr. Whitehead, and Dr. Ross. He is a clerk by occupation, is twenty- four years of age, and gives the following account of himself. At birth he had a swelling (spina bifida) which was never larger than an orange, over the lower part of the back. Very soon after birth a needle was thrust into this, but he does not know whether any effect ensued. When two years of age he was said to have had a fit, followed by paralysis, and subsequently wasting of the muscles below the knee on both sides. He also states that there was some contraction of the calf-muscles, causing drawing up of the heel, which on two occasions required division of the tendo Achillis, followed by the use of a metal boot. The deformity was thus eventually overcome. When about fifteen years of age he began to be troubled by an ulcer on the outer side of the right foot, which resisted all treatment, until in 1883 the little toe, with its metatarsal bone, was amputated by Mr. Lund. The wound thus caused remained open for nineteen months, at the end of which time its upper end had again formed an ulcer. This ulcer still remains, and is his chief trouble ; it improves when he is confined to his bed, but soon breaks down again when he tries to move about. The condition of the patient never varied very materially at the various times, extending over a period of some eighteen months, during which he was under observation, and he presents the following points. On the back, opposite to the last lumbar or first sacral vertebra, is a flattened swelling about the size of a hen's egg, but of lenticular shape and covered with hair. At its centre is a de- pression, into which he states that a stocking-needle was passed at birth ; but he also says that the depression was congenital, and that the needle was used only to probe its depth. The swelling is of an elastic consistence, and gentle manipulation causes sen- sations which the patient says are pleasm*able but indescribable. Firm pressure causes passage of urine, defecation, and strong sexual desire ; a blow upon it causes some rigidity of the legs. Over the swelling is a luxuriant growth of hair, which is also well-developed on the lower limbs. Both the lower limbs show distinct wasting, which is more INJURIES TO THE CAUDA EQUINA. marked on the right than on the left side, the circumferences being : right calf, 8 inches ; left calf, I I inches ; right thigh, 14^ inches; left thigh, 17 inches; while the right is half an inch shorter than the left limb. On the right side, the fifth toe and its metatarsal bone were removed, and on the outer side of the foot over the fourth metatarsal is an oval ulcer about one inch long and half an inch wide. The ulcer shows a clean-cut margin, which is raised, horny, and thickened, with slight under- mining of its edges and pale granulations at its base. Between the second and third toe on the same foot was at one period a second small ulcer, which recovered with rest. The arch of the foot is exaggerated, the toes pointed, and there is no power of movement about the ankle-joint. The lower limbs are partially paralysed, with weakness and wasting of most of the muscles, and especially of those below the knee, the leg-muscles of the right side being completely paralysed. The knee-jerk, ankle-clonus, and plantar reflex are absent on both sides ; the cremasteric, abdominal, and epigas- tric reflexes normal. The electric reactions of the muscles are as follows : RIGHT SIDE. LEFT SIDE. K. C. C. A. C. C. K. C. C. A. C. C. Cells. Cells. Cells. Cells. Sartorius 40 40 35 40 Adductor magnus 25 30 35 45 Gluteus maximus nil nil 50 nil Vastus externus 25 40 40 50 Vastus interims 45 40 45 nil Gastrocnemius . 45 50 2 5 40 Peroneus longus 50 nil 40 35 Tibialis anticus 45 45 40 nil Hence they do not present the " reaction of degeneration." To the faradic current they react with difficulty on both sides, the anterior muscles of the left thigh acting most readily, those of the right foot not at all. He has difficulty in walking, being always afraid of falling, and in the dark he staggers and has to grope his way. The walk is characteristically " pseudo-tabetic," resembling that of locomotor ataxia in its sprawling hesitating character, but unlike the gait seen in that disease, in that the toes drop at each step. At times, especially if he is tired, there are slow fibrillar movements of the muscles of the right thigh 88 SURGERY OF THE SPINAL CORD. and gluteal region, with occasional choreiform movements of the right foot. As regards sensation, the patient states that he cannot judge of the position of his right lower limb, and that the ground does not feel solid under his feet. At times the limbs feel " as if they did not belong to him, but were some distance off." He occasionally has pain in the dorsum of the right foot, and in the knees and hips, and intense tickling sensation in the sole of the right foot. On examination, there was found to be extensive anaesthesia of the lower limbs, of similar distribution on both sides. The affected area was not quite sharply defined, but had the general FIG. ii. FIG. 12. outline, represented in the accompanying diagrams, where the anaesthetic portion is shaded. Commencing above at the side of the tumour and almost at its centre, the boundary-line runs down- wards and outwards, across the upper limit of the gluteal region, thence, over the great trochanter, down the outer side of the thigh to the apex of the line leading to the external condyle ; it now tends forward, somewhat to the front of the condyle, and then down along the line of the fibula for about half its length ; after INJURIES TO THE CAUDA EQU1NA. 89 which it comes forward and inward across the shin, ending about the middle of the first metatarsal bone. The inner boundary commences about the external inguinal ring, passes outward towards Poupart's ligament ; thence slightly backwards for a short distance ; again down the inner aspect of the thigh to the back of the internal condyle ; thence down the inner side of the leg, curving below the internal malleolus, and running forwards to join the former line over the metatarsal bone of the great-toe. It will be noted that the anaesthetic area includes the gluteal region, the back of the thigh, the back and part of the outer side of the leg, and the whole of the foot, except a small area on its inner aspect. Further, the perineum is included in its boundaries, being absolutely anaesthetic. .The penis also is anaesthetic, except at its extreme root, as is the scrotum, except along a line too small to represent in the diagram, extending forwards and downwards from the external ring for about two inches, and corresponding apparently to the distribution of the ileo-inguinal nerve. Although the scrotum is thus anaesthetic, testicular sensation on deep pressure is normal. At one period he states that he passed urine involuntarily, and had to wear a bag to catch it ; but he can now retain it, and indeed only passes it with difficulty and much straining. He knows when the bladder is full. The bowels are usually relaxed, and at times he has involuntary evacuations. He is not always able to tell whether he has or has not passed urine or faeces. He has sexual sensations and enjoyment, but states that on con- nection the semen is usually ejaculated before intromission, but that on a second coitus he can perform the act as usual. He says that when under the influence of drink he can both pass his urine without difficulty and complete the sexual act on the first attempt. He is subject to attacks of lymphangitis and swelling of the inguinal glands in the right lower limb, which attacks he believes to have a tendency to monthly periodicity, and to be brought on in many instances by drinking or by sexual excitement. This case resembles the last very closely, differing mainly in the less complete paralysis and in the partial reaction of degenera- tion replacing the complete degeneration shown by Case 29. The distribution of the anaesthesia is similar to that of Case 29. An interesting point is the retention of sexual desire and enjoyment in spite of the complete anaesthesia of the penis, and the evidence of persistence of sensation in the testicles, which derive their sensory nerves from a higher level of the cord than does the 90 SURGERY OF THE SPINAL CORD. scrotum. The paralysis is again seen to affect mainly the branches of the sciatic, gluteal, and pudic nerves, sparing the anterior crural and obturator with the upper lumbar branches. That the lesion is a compression of the cauda equina by the cicatrix of the spina bifida there can, I think, be no doubt. The trophic lesion of the right foot is interesting, and is similar to that seen in a case reported by Mr. Ogston l of old spina bifida with perforating ulcer of the left foot, anaesthesia of the outer side of the leg and dorsal and plantar aspects of the foot, and diminished faradic contrac- tility of the muscles of the foot, all on the same side. Indeed, Ogston's case is clearly of the same nature as the above, differing only in that the cicatrix had, in his case, involved but a portion of the fibres of the sciatic of one side only. Another similar case is reported by Brunner 2 as an instance of spina bifida occulta. The patient had a depression over the spine extending from the first to the fifth lumbar vertebra, excessive growth of hair over that region, and a perforating ulcer on the outer side of the right foot. The right lower limb was wasted, especially below the knee, and there was some loss of power in it : there was anaesthesia of the sole and outer side of the foot ; the knee-jerk was lost. Mr. Bland Sutton 3 has recorded another case of perforating ulcer due to spina bifida occulta, but we have no information as to the sensory and motor functions. He refers, further, to similar cases recorded by Recklinghausen and Fischer, the former presenting a perforating ulcer, the latter, chronic ostitis of the metatarsus, and both having anaesthesia of the feet. The next case presents closely similar symptoms arising from the pressure of a tumour upon the cauda equina. CASE 31. Tumour of cauda equina. Joseph Davies was admitted under the care of Dr. Ross on May 12, 1882. His previous history presented nothing of inte- rest. About five months before admission he began to suffer from pains shooting from the small of the back down the backs of the thighs and legs to the feet, which gradually increased until he was unable to bend his back and could hardly walk. On admission, he complained of the above pain, and of great pain in the buttocks when sitting down. He could hardly walk, 1 Lancet, 1876, vol. ii. p. 13. z Virchow's Archiv, 1887, p. 494. 3 Lancet, 1887, vol. ii. p. 4. INJURIES TO THE CAUDA EQUINA. 91 dragging the legs along the ground slowly and with difficulty, and the lower limbs were much wasted. The patellar reaction was increased on both sides. The urine was retained, and had to be drawn off with a catheter. Pupils presented no abnormality. He was treated with strychnia and iron. The notes at this period are very imperfect, but there seems to have been little or no change for a long time. On July 5 he was ordered gr. v. doses of iodide of potassium. On July I 3 it was noted that pain was greatest about the ankles and outer sides of the feet. There was no staggering in the gait, nor did he sway when standing with the eyes closed, but the movements of the lower limbs were very feeble, those of the gluteal muscles being especially so. The plantar and cremasteric reflexes were well marked, but the gluteal was sluggish. The patellar tendon reaction was lively (? exaggerated) on both sides. On both sides the muscles of the lower limbs were markedly atrophied, and, with the exception of the gluteus maximus of the left side, had lost their faradic contractility, this muscle also only reacting to strong currents. Analgesia and diminution of tactile sensibility were present over the back of the sacrum, extending thence to the perineum, the left side of the scrotum, the backs of both thighs, and down the calves in the form of a triangle, with the apex downwards. Four days later the anesthetic area was found to have extended so as to involve the buttocks up to the level of distribution of the ilio-hypogastric nerves, the backs of the thighs, and the bulk of the leg, omitting, however, the front of the knee-joint, inner border of the tibia and foot, and the great-toe (i.e., the distribution of the internal saphenous nerve). The anesthesia was less perfect in the legs than in the buttocks. On going to stool, the patient could not pass a motion until he had pressed upon the perineum, but very light pressure even merely wiping the anus was sufficient, so that the action was probably not entirely mechanical. Pain in the lower limbs was very severe, especially on movement, and he had often much pain about the anus ; those symptoms being so severe as to necessitate hypodermic injections of morphia. A month later he could still move the lower limbs in all direc- tions, but only with the greatest difficulty, and apparently some- what better on the right than on the left side ; there was also extreme wasting of the limbs, but it was difficult to say that one group of muscles was more affected than another. The plantar and cremasteric reflexes were exaggerated, the gluteal absent on both sides. The knee-jerk was, as before, well marked, but there r 92 SURGERY OF THE SPINAL CORD. Vas no ankle-clonus. With the faradic current the gastrocnemius Fio. 13 Fio. 14. and glutei gave no reaction ; the anterior leg-muscles and all INJURIES TO THE CAUDA EQTJINA. 93 those of the thigh reacted to a current of medium strength. The following table shows the number of cells required to produce contraction with the constant current : KatliocUl Closure. Anodal Closure. Cells. Cells. Biceps femoris (right) 30 30 . (left) . 35 30 Gluteus maximus (right) 20 2O (left) '5 25 Extensors of foot (right) 40 40 (left) 40 40 Extensors of knee (left) 30 45 Gastrocuemius (right) 30 35 (left) . 45 45 FIG. 17. The distribution of the anaesthesia at this date is indicated by the accompanying diagrams (figs. 13-17)- Pain was still very great, but the general health re- mained fairly good. There was some redness over the trochanters and sacrum. From this time the patient lost ground rapidly. The skin became sore at several points, an abscess formed over the right trochanter major, the pain was intense, the appetite failed, and the temperature became hectic, varying from 97 in the morning to 103.6 in the even- ing. On September 1 1 he was or- dered drachm doses of liq. hyd. perchlor. with grs. ij. of pot. iod. three times a day, but no improvement followed. Morphia had to be used constantly. On November I a bed-sore formed over the sacrum, and on November I 5 he had convulsions and died in the afternoon. No notes were taken of the post-mortem examination, but Dr. Ross, who was present, and Professor Young, who was at that time pathologist to the Infirmary, remember that there was found only a very small tumour a fibro-sarcoma about the size of a hemp-seed situated on one of the nerve cords of the cauda, with no signs of diffused infiltration or inflammation. It is, however, obvious that there must have been some lesion of more than the one nerve root, and no microscopic examination was made of the others. The spinal cord itself was perfectly normal. 94 SURGERY OF THE SPINAL CORD. We have here the same distribution of anaesthesia as in Cases 29 and 30, but the notes contain no reference to the relative power of the thigh-muscles. The reaction of degeneration was again absent. Owing to the nature of the lesion, the anaesthesia was preceded by intense pain, and the symptoms were at first more marked on the left than on the right side. The retention of the knee-jerk and plantar reflexes is unusual, but some exaggeration of reflex action is by no means rare in the earlier stages of peripheral nerve-lesions, before irritation has given rise to complete annihilation of function. The nature of the lesion was here placed beyond any possible doubt by the post-mortem examination, which showed that the cauda equina, and not the spinal cord itself, was the region involved. A closely similar case is mentioned and figured by Dr. Gowers, 1 who notes that tactile sensibility was impaired " chiefly in the region supplied from the sacral plexus," and that although the lower limbs were paralysed, " a little power in the flexors of the hips and extensors of the knees persisted almost to the last." Hence, in Dr. Gowers' case also the anterior crural nerve was less profoundly affected than the branches below it. His figure shows a tumour of the cauda equina immediately below the termination of the cord. CASE 32. Dislocation forwards of the second lumbar vertebra Compression of the cauda equina. R. M. C., aged fifteen, male, a collier by occupation, was admitted to the Infirmary under Mr. Jones's care on December 31, 1886. About the end of the previous August, while he was in the pit, and probably in a stooping posture, a stone weighing five or six cwts. fell from the roof a distance of about five feet on to his shoulders, bending him forwards with his head between his knees and his right leg under him. On being extracted, he was found to have a fracture of the right femur, and this was ap- parently the only injury diagnosed at that time ; but he had much pain in the lower part of the back and in both hips, and was unable to sit up in bed. Some nine weeks later, he could sit in a chair. He was never able to move his feet after the accident, and not for a fortnight had he any power over either thigh. He had never any pain or other unusual sensations in the fractured 1 Diseases of the Nervous System, vol. i. p. 420. INJURIES TO THE CAUDA EQUINA. 95 limb, from which we may assume that it was anaesthetic. For six weeks after the accident his urine had to be drawn off systematically with a catheter, and from about the third week he had symptoms of cystitis, which still continued on admission. Since the sixth week no catheter has been used, and he has been able to pass water, nor has he ever had any incontinence ; but micturition is very slowly performed. Constipation has been present throughout, but there has never been any involuntary defecation. On admission, we found a prominence of one of the lumbar spinous process (the third) one inch above the level of the pos- terior superior iliac spines. Above and below this were depres- sions, and to the left of, and a little above it, another bony prominence, due apparently to the displaced transverse process of the second lumbar vertebra. There was slight pain and ten- derness in this region. The lower limbs presented partial paralysis, but could be moved about the bed to some extent. The hips could be moved in every direction, but adduction was more powerful than any other movement ; extension and flexion were about equally vigorous, and abduction very weak ; at the knee extension was more powerful than flexion. In the ankle and foot no movements could be produced. The muscles of the buttocks and lower limbs were wasted, those below the knees being especially so ; none of the lower limb muscles contracted with a faradic current of such strength as the patient could bear, but we were unable to test the galvanic reactions satisfactorily. The knee-jerk was absent, as was the plantar reflex, the cremasteric and gluteal being well marked and apparently exaggerated. There was nowhere absolute anaesthesia, but sensation was obtuse over the lower part of the gluteal region, and thence down the back of the thighs and legs to the soles of the feet, as well as over the front of the legs and the dorsum of the feet. It was much less imperfect on the front of the thighs than elsewhere in the lower limbs, and was better on the inner than on the outer side of the legs. Over the genitals also sensation was much blunted, but not absent, and a catheter was felt along the whole of the urethra. The passage of faeces was also felt. He stated that sensation had gradually improved since the accident. The feet always felt cold to the patient, but there was no pain or hyperaesthesia. The skin of the lower limbs presented no abnormalities. Pria- pism was common ; the urine was alkaline, containing some pus 96 SURGERY OF THE SPINAL CORD. and phosphates, and there was pain over the pubes, and smarting on micturition. On January 1 5th a fortnight after admission Mr. Jones proceeded to trephine the spine in the affected region. Chloro- form having been administered, the patient was turned on to his face, and an incision four inches in length was made in the middle line, with its centre over the prominent spinous process. From either end of this an incision of some three inches in length was carried at right angles to it, and to the left. The superficial structures were thus dissected up in a flap, and the muscles were then separated by blunt dissection, drawn aside from the vertebral groove, and held back by retractors. It was now clear that the arch of the second lumbar vertebra was displaced forwards, the prominent spine being that of the third, so that the displacement was that most commonly met with dislocation forwards of the upper part of the spine. At the same time the spine of the second lumbar vertebra was broken off and isolated, and the prominence above mentioned as lying to the left of the middle line proved to be the articular process of the third lumbar, its articular surface being exposed by the dislocation forwards of that of the second. The detached spine of the second vertebra was removed, and showed a gap between the arches of the second and third, filled with dense cicatricial tissue. By means of bone forceps, the arch of the second lumbar was now almost entirely removed, exposing the membranes of the cord, which had obviously been compressed by it. Around these membranes there was also cicatricial tissue, which was not interfered with. The flap was replaced and sutured, a drainage tube being placed at its lower angle, and the wound dressed with wood-wool. No trouble followed the operation, and the wound healed well, but rather slowly, the temperature being more or less raised for about a fortnight afterwards. Five days later the patient stated that the sensation of coldness in the feet had disappeared. After a week the faradic current was used to the muscles, and caused slight contractions in the posterior thigh-muscles, a more marked effect in the anterior muscles and adductors, but none in the legs. The galvanic current was never used, as the patient would not submit to it, and struggled when it was tried. Sensation improved somewhat, and the thigh-muscles became much stronger during the ensuing two months, but no power of motion returned in the leg- muscles. In this condition he was sent to the Convalescent Hospital at Cheadle on April 2, two months and a half after the operation. INJURIES TO THE CAUDA EQUINA. 9? A month later, when I saw him at Cheadle, he could stand up, and could, by means of chairs, &c., walk a little ; the thigh- muscles were fairly developed, and the hip and knee joints freely movable, but the leg-muscles remained atrophied, and he could not move the ankles or toes. The thigh-muscles reacted to the faradic current, but those of the legs did not ; it was not possible to obtain accurate galvanic observations, but apparently the ascend- ing and descending currents were equally effective in producing contractions of the thigh-muscles, and equally unable to affect those below the knees. Occasionally he had muscular tremors. Sensation appeared to be everywhere normal, but was perhaps a little less acute on the outer than on the inner side of each leg. The superficial reflexes were well marked, the knee-jerk absent. A small quantity of pus still remained in the urine, but this slight cystitis caused no subjective symptoms. A fortnight afterwards, when I saw him again, he could walk with the aid of one stick only, but with marked dragging of the toes. There was no other change. About eighteen months after the last date this lad was shown by Mr. Jones to the members of the Manchester Medical Society. He was then at work as a collier, and could, with the aid of a stick, walk several miles, but the muscles of the feet and flexors and extensors of the toes remained paralysed, and there was some contraction of the posterior thigh-muscles, causing the knees to be always slightly bent. The relationship of this case to the three first cited is obvious, and the localisation of the lesion indubitable. The most interest- ing point in the symptoms is the slight interference with sensation as compared with motion. We are now in a position to compare the above four cases, which, although differing somewhat in their details, resemble one another sufficiently in their broad outlines to form a distinctly marked group. For this purpose I have arranged the leading symptoms in the form of a Table, showing the similarities and points of difference in each case. 98 SURGERY OF THE SPINAL CORD. S - fa 3 . "8 'S O -^ 11 3 g &^ s Is d) CD c.5 3 r3 S3 " & 3 c5 g .2 CO 2 .9 o fa ^ fa S s i M o o B CO ^ o> -g <= 11 n 11 si '5 S 2 2 &"_, *O & *d a ,Q T3 CJ * 2 8 s^'fa . a 03 r5 *" s S ^5 o a . If JS co J3 fill I "3 i all n 3 S 1 |ll 2 c '43 o C '43 |l CD 5 O P PH fe 8 i i t- i-^ i a a to eg ."s w 3 .2 *O (H 'o 1 C PH a, t 1 1^ ^^ 00 g 3 _O m _^ 1 s 'C m - 'C S CO O = 1 A2 CO 11 "= J "rt Jj ^ H fa fa" CD" <3 O~ .2 o | O s 1 1 1 ili B>1^ F O in 3 rt "" ^ c3 Q *~ H i^ "^ CD P P-l rH O *^ s+ C3 -*- 1 cS o ^ ^3 ** o Spina bifi CD J3--5 -g . ^ "3 '-g s ^ a i * 1 1 113 PH Patellar Cremas 1 I 1 |'l Erections ating u! 1 Dislocation of first lumbar vertebra. Complete in distribution of sciatic and pudic nerves. Partial in anterior crural and obturator. In distribution of anterior crural, obturator, sciatic (and pudic) nerves. Patellar and plantar lost. Cremasteric normal. In distribution of great and small sciatic and pudic nerves, and in posterior sacral branches. Slight if at all in external cu- taneous, anterior crural, or obturator. Retention of urine. Incon- tinence of faeces. No erections. Bed-sores on heels. a S I o fa "rt s *> fa V a . . M n . M 1 cS *o .2 1 I CO a S c -2 '3 i X region. up both legs, the right with greater difficulty p. 326. tban the left. INJURIES TO THE CAUDA EQUINA. IOI Anaesthesia. Bladder and Rectum. Vase-motor and Trophic. Local Symptoms. Post- mortem. Remarks. Numbness and ting- Occasional Coldness of Tender- There were ling on outer side loss of extremities, ness over also symp- of left thigh ; par- control especially third toms of tial loss of sensa- over of left lumbar cervical tion below left sphincters. foot. vertebra injury. knee. Right limb after loth normal. day. Diminished sensa- Retention No note. Gunshot Author re- tion below seat of of urine. wound. gards as a injury. Hyper- case of con- sesthesia of front cussion, and inner side of because the thigh. Ansesthesia retention of of urethra anterior some sensa- to pars prostatica. tion shows that there was no serious cord lesion. Absolute anaesthesia Inconti- None. Gunshot Case seen of postero-inter- nence of wound. nine years nal and anterior urine. after injury. parts of thighs ; of penis and scrotum. After two years anaes- Involuntary No note. Contusion Reported thesia of feet, back urination in lumbar as a case of of legs, thighs, and defse- region. concussion. buttocks, scrotum, cation. and penis. Perfect sensation in front of limbs from groin to ankle. Complete anaesthesia At first Bed-sore. Absent. Fracture of of soles ; partial retention, body and loss of sensation of later dislocation rest of limbs, ex- dribbling forwards of cept front of of urine. second thighs. Sensation Retention lumbar ver- better on inner of faeces. tebra, the than on outer side cauda equina of thighs. Some- being times felt passage ' ' lifted on of catheter. a bridge of displaced bone." Anaesthesia of geni- Retention No pria- Promi- From the tals, but condition of urine. pism. nence of distribution of limbs not at first Involuntary the spine of the anaes- noted. Felt pain defaecation. ' ' in the thesia, and when catheter en- Urine am- lumbar from the po- tered bladder. On moniacal region. " sition of the 8th day had perfect for a time. spinal pro- sensation in front On 39th day minence, of thighs. On 39th had desire, the author day had sensation but no thought in front of thighs power to it probable and legs, in hypo- pass water. that the gastric region and lesion affec- scrotum; good sen- ted the sation in first and fourth or second toes, par- fifth lumbar tial in the others. vertebra. Complete anaes- thesia of back and inner sides of thighs. IO2 SURGERY OF THE SPINAL COED. Case Reference. Sex. Age. Result. Probable Lesion. Paralysis, &c. Reflexes. G. Eutchinson, M. 33 Partial Dislocation Paralysis of lower limbs No note. Lond. recovery of second f ollowedby some wast- FIosp. Rep., in three lumbar ing, especially of vol. iii. months. vertebra. glutei. P- 332. H. M'Donnell, M. 3 1 Partial Fracture At first, paralysis of No re- Dublin Quart. Jour recovery in twelve in upper lumbar lower limbs. At end of second month, com- flexes below Med. Sci., months. region. plete paralysis below knees. 1866. the knees, and very Exagge- vol. xlii. little power in the rated in thigh-muscles except thighs. the sartorius. K. Leyden, M. 45 Death in Fracture- Lower limbs were para- "Not in- Klinik der seven dislocation lysed, but some power creased" Rttcken- weeks. of first remained in adductors marks- lumbar and anterior muscles krankhei- vertebra. of left thigh. After ten, vol. ii. three weeks there P- 143- were cramps. INJURIES TO THE CAUDA EQUINA. IO' Anaesthesia. Bladder and Kectum. Vaso-motor and Trophic. Local Symptoms. Post- mortem. Remarks. Anaesthesia of scro- Retention Projection tum, penis, and of urine of third urethra ; partially and faeces. lumbar of thighs ; com- vertebra. pletely of legs. At interval of three months, anaesthe- sia of feet, but- tocks, and peri- neum ; numbness of penis, scrotum, and urethra ; fairly good sensation in thighs ; better sen- sation on soles , than on dorsum of feet, and on inner than on outer side of leg. At first anaesthesia Retention Occasional An im- The spine of lower limbs. At of urine, priapism. movable was tre- end of two months followed in Wasting of projection phined. had anaesthesia of four or five lower limbs. four inches which was feet, obscure sen- days by Perspiration above level followed by sation from ankle inconti- of feet and of um- some im- to knee, especially nence. Am- ankles. bilicus. provement on left side ; moniacal (Edema of in the hyperaesthesia of urine. penis and symptoms. thigh, especially on right side. scrotum. Urethritis, cystitis. Bed-sore on back. Anaesthesia of lower Retention No erections. No note. Fracture of See text. limbs, except from of urine Sweating first lumbar This is front of left thigh and faeces. of feet ; vertebra, the given by to dorsum of foot, oedema of cartilage the author the loss of sensa- lower immediately as a typical tion extending as limbs and below which case of high as the but- scrotum. projected traumatic tocks and sacrum, Bed-sores of backwards myelitis. affecting also the feet and some J inch penis and urethra ; sacrum. (7 mm.). but less marked Lumbar cord on the front than swollen, soft on the back of the and pale. thighs. Hyper- Other secon- aesthesia in in- dary lesions. guinal region , shooting pains in limbs and pain in bladder. 1O4 SURGERY OF THE SPINAL CORD. Case Reference. Sex. Age. Result. Probable Lesion. Paralysis, &c. Reflexes. L. Leyden, M. 3 2 Death in Fracture Lower limbs almost com- tfonote. Klinik der five of twelfth pletely paralysed, but K-ucken- months. dorsal and had some power of ro- marks- first lumbar tating and adducting krankhei- laminae. thighs, and attempts ten, voL i. at flexion of knees. p. 340. Complete passive flexion of knees pre- vented by spasm of quadriceps. Adduc- tion and inwards rota- tion of left thigh. Occasional cramps and tremors. Muscles of legs and back of thighs did not react to farad. current, but those of front of thighs did so readily. M. Hamilton, M. 2 5 Death in Fracture Paralysis of lower limbs. No note. Dublin two through Quart. Jour. months. body and Med. Sci., laminae of k vol vi. second 1848. lumbar vertebra. N. Hutton, Dublin M. Death in six weeks. Fracture of first Loss of power of the lower extremities. No note. Jour. lumbar Med. Sci., vertebra. vol. xxi. 1842. I shall not add anything with regard to the details of the symptoms in the above, which are sufficiently similar to my own cases, but merely wish to adduce evidence in favour of their being due to pressure upon the cauda equina. Case A. is attri- buted by the author to " intraspinal haemorrhage," but the date of appearance and the seat of tenderness would seem to warrant the interpretation given in the Table. Case B. appears to me to be most typical, and I entirely fail to appreciate the reason INJURIES TO THE CAUDA EQUINA. 105 Anaesthesia. Bladder and Rectum. Vasa-motor and Trophic. Local Symptoms. Post- mortem. Remarks. Anaesthesia not com- Retention Slight Spinous Fracture of Death from plete, but sensa- of urine oedema process of twelfth dor- uraemia. tion almost lost in and faeces. of legs. first lum- sal and first the feet, very Bedsore on bar verte- lumbar lami- obscure in legs, sacrum. bra pro- nae, and of back of thighs, jected body of first and buttocks ; bet- backwards lumbarverte- ter in front of and to the} bra ; tear of thighs. right. dura mater ; compression of cord and caudaequina. Inflamma- tion of pia mater and softening of cord extend- ing to upper level of lum- bar region. Secondary lesions. At first there was Retention Projection Fracture Death from anaesthesia, except of urine, of second through erysipelas. on the front of the thighs. In a few followed by symptoms lumbar spine. upper part of body of days this region of cystitis. second was also affected, lumbar but again re- vertebra and covered. its laminae, with com- pression of the cord "just above the cauda equina." The " external parts Retention Bedsore on Interval An oblique of the lower limbs of urine left buttock. between fracture of were quite insen- and faeces. The right last dorsal the body of sible, the internal Cystitis. tibia and and first the first still retaining a fibula were lumbar lumbar ver- considerable share also broken vertebrae. tebra, with of sensibility." and united compression readily. of the cord Temp, of and cauda lower limbs equina, was "at which were first " 62, bathed in afterwards pus. 95- given for regarding it as an instance of " concussion." The lesion was below the region of the cord itself and over that of the cauda equina, and the symptoms are those of pressure upon, or partial destruction of, the latter. In Case F. Mr. Hutchinson places the probable seat of the lesion at the fourth or fifth lumbar vertebra, a conclusion which, in view of our cases, is hardly warranted by the nature of the nervous symptoms described. At first all the muscles of the lower limbs seem to have been paralysed (unfor- 106 SURGERY OF THE SPINAL CORD. tunately, sensation was not at that time accurately noted), thus, it would seem, indicating that the entire cauda equina was primarily paralysed, but that recovery of the higher roots rapidly ensued. The best description is that of Leyden (Case K.), who appears to have attributed the symptoms mainly to myelitis, and not to the crush of the cauda equina ; but although the co-existence of myelitis is proved by the post-mortem appearances, the site of the lesion and the fact that the symptoms followed immediately after the accident, appear to indicate a primary lesion of the cauda equina. In the other cases, the localisation is, as a rule, obvious enough from the facts above furnished. In conclusion, I would draw attention to certain points in the diagnosis of these cases of pressure upon the cauda equina. 1. From locomotor ataxia. In a traumatic case there is little likelihood of confusion, although even here the affection might possibly be regarded as ataxia consequent upon an injury. But in a case of tumour or spina bifida, &c., the occurrence of a perforating ulcer, pains in the limbs, patches of anaesthesia, loss of knee-jerk, and some difficulty in walking, with or without bladder troubles, might well mislead the unwary. We must then note the absence of pupil symptoms, of girdle-pains, gastric crises, &c. ; on the other hand, we shall find the peculiar distri- bution of the anaesthesia as above described ; the affected muscles will be more wasted than in ataxia, and may present the reaction of degeneration, and there will be loss of power as well as inco- ordination. The gait differs from that of ataxia, and is charac- teristic, there being not only clumsiness and sprawling, but marked dropping of the toes. 2. From injury or disease of the lower part of the spinal cord. Here we must be guided by the exact site of the local symptoms, if any be present, remembering that the cord does not extend below the lower border of the first lumbar vertebra. Failing this, the diagnosis becomes one of very great difficulty, the only other differential symptom being the existence of con- stant pain or hypersesthesia above the ansesthetic region, a condi- tion which points rather to the cauda equina than to the cord itself as the seat of disease. In lesions of gradual increase, such as tumours, the rate of production of the various symptoms will assist us, as in Case 48, where a history of six years' progressive development points rather to an affection of the cauda than of the spinal cord. Asymmetry of the symptoms also probably indi- cates a lesion of the cauda equina. INJURIES TO THE CAUDA EQUINA. 1 07 3. From extra-spinal diseases and injuries of the nerves to the lower limbs. We have here several difficulties to contend with, but in most instances a careful consideration of the case will lead to a correct conclusion. The only peripheral disease liable to be mistaken for an affection of the cauda equina is some variety of multiple peripheral neuritis, and here we may usually decide the point by finding some affection of the upper limbs, by the marked preference of that disease for the extensor surfaces, and by the slighter sensory symptoms. In cases of injury the difficulty is greater. Even the limitation of symptoms to one side of the body is not an absolutely pathognomonic sign, as is indicated by Mr. Erichsen's case (Case A., Table). Nevertheless, complete unilateral distribution or perfect symmetry would be strong arguments for the lesion being respectively outside or inside the spinal canal. We are again aided by the site of any local signs of injury ; and finally, we might with certainty pronounce the case to be an affection of the cauda if we found the distribution of the sensory and motor symptoms to accord closely with the above-described types. CHAPTER V. INJURIES OF THE LUMBO-SACRAL REGION OF THE SPINAL CORD. As in the case of the cervical region of the spinal cord, we may, before entering upon a study of traumatic lesions of the lumbo-sacral region, recapitulate briefly the conclusions of previous observers regarding the functions of the various nerve-roots which constitute the crural plexus. These conclusions are derived from two methods of research the experimental and the clinical and hitherto they have not been verified by any accurate anatomical investigations corre- sponding to those of Herringham upon the roots of the brachial plexus. Drs. Ferrier and Yeo, 1 observing the effects of experimental irritation of the several roots of the crural plexus, classify as follows the muscles supplied by each : Third lumbar type : Ilio-psoas, sartorius, adductors, extensor cruris. Fourth lumbar type : Extensors of thigh, extensor cruris, peroneus longus, adductors. Fifth lumbar type : Flexors and extensors of toes, tibial muscles, sural muscles, peroneal muscles, outward rotators of thigh, hamstrings. First sacral type : Muscles of calf (plantar flexors), ham- strings, long flexor of big-toe, intrinsic muscles of the foot. Second sacral type : Intrinsic muscles of the foot. The objections to an implicit reliance upon these experimental results have been already indicated in considering the analogous 1 Brain, vol. iv., 1882, p. 226. INJURIES OF THE LUMBOSACRAL REGION. IO9 observations upon the brachial plexus, but, as in the latter case, we find that they agree in the main with the results of clinical experience. The classification of Dr. Gowers l is derived from a comparison with the above of such scattered clinical records as throw any- light upon the distribution of functions, and the results thus obtained are embodied in the following Table : Root. Motor. Sensory. Reflex. First lumbar . ) Groin and scrotum \ Second lumbar . ) Cremaster. p *$ j (front). 1 V \ Cremas- Third lumbar . J Flexors of hip. g. 3 ) Extensors of knee. 5" ( Outer ( ) ( teric. 1 side. ) (Knee- Fourth lumbar. j Adductors of hip. \ ' ) Extensors and ab- 1 (3 Jl > Thigh /Front. \ ) jerk. j Inner I \ Fifth lumbar . First sacral Second sacral . Third sacral Fourth sacral . ) ductors of hip. > H. > Flexors of knee. 1 o / "-> (Intrinsic muscles of 3 1 foot. Eg )Perineal and anal ' J muscles. ) Leg (inner sidS flk** ; ) \Foot- . Buttock(lowerpart)^ \ ( clonus. Back of thigh. 1 \ ' Plantar. Leg and foot ex- r ) j cept inner part. ) > Perineum and anus. Fifth sacral Coccygeal . . ) Skin from coccyx to ) anus. If, now, we endeavour, as in the cervical region, to obtain from an examination of cases of spinal injury fresh data for accurate localisation, we at once find ourselves confronted by several diffi- culties which render useless the method pursued in the earlier investigation. In the first place, death comparatively rarely follows injuries in the lumbar region, so that we have not the advantage of an absolutely accurate localisation. The cases also which are met with in an individual experience are too few for generalisation. Again, owing to the fact that the whole of the nerves of the lumbo-sacral plexus originate from the spinal cord within the short vertical extent of the last dorsal and first lumbar vertebrae, it is practically impossible to find spinal injuries which accurately cut off their separate levels of origin. And, finally, most important of all, is the fact that the nerve-roots of the lower portion of the cord have so extensive an intraspinal course that they are generally implicated together, and, owing to the solidity of the sacrum, do not become separately cut off by lesions near their points of exit. But, in spite of these difficulties, it is possible, by a careful comparison of cases, to obtain, from the evidence supplied by 1 Diseases of the Nervous System vol. i. p. 142. I I O SURGERY OF THE SPINAL CORD. spinal injuries alone, a fairly accurate conception of the functions of each of the nerve-roots which enter into the lumbar and sacral plexuses. The following cases, partly original and partly quoted, are intended to illustrate these functions, and will be found to supply a tolerably complete picture of the effects produced by their loss. As in nearly all these cases the lesion was so situated that all the nerves of the cauda equina might possibly have been affected, it will be necessary to make certain assumptions, viz., first, that if after a crush of the cauda, certain fibres are injured and others not, the injured nerves originate lower that those which are spared ; and second, that where destruction of certain functions is partial only, then, the more complete such destruction, the lower is the nerve whose injury has given rise to it. The ground for these assumptions is that, as a matter of fact, we seldom find nerves, known to arise high up in the crural region, injured whilst those below them have escaped, a general pro- position for which the evidence will be found in the preceding chapter (p. 99). It will again be convenient first to present in tabular form the results at which I have arrived, and then to consider in detail the evidence upon which the conclusions are based. In the Table thus given, it is to be distinctly understood that I have inserted only so much of the distribution of each root as is illustrated by the following cases. Thus, although there is no doubt whatever that the second lumbar root supplies muscular branches, these are here ignored because the cases yield no evidence of the same. The separation of some of the roots will be seen to be, to a certain extent, arbitrary, and it is not improbable that, owing to the physiological requirements of the lower limb, the specialisation of the spinal nuclei and the concomitant isolation of their efferent motor fibres are less marked than in the case of the upper extremity, and that I may thus have ignored minor nervous connections running in roots other than those which supply the chief motor branches to each muscle ; but, as already suggested, it is probable that this very absence of accurate detail itself renders the results of the more value as a practical clinical guide, for which purpose we require to know only such relationships as will influence the production of symptoms. INJURIES OF THE LUMBO-SACRAL REGION. I I I Root. Motor Distribution. Sensory Distribution. First lumbar . . . Second lumbar . . Third lumbar . . . None. None. Sartorius. Adductors of thigh. Flexors of thigh. Ilio-hypogastric and ilio-in- guinal. Outer (?) and upper part of thigh. Anterior aspect of thigh be- low second lumbar root. Fourth lumbar . . Extensors of knee. Abductors of thigh. Anterior and inner part of leg. Fifth lumbar . . . Hamstring muscles. Back of thigh, except in dis- tribution of first, second, and third sacral. First sacral . . . \ ICalf muscles. ) . Second sacral . ./ Glutei. i Peronei. Extensors of ankle. 1 "j Intrinsic muscles of }- ' foot. J 0) "a S .6 A narrow strip on back of thigh, back of leg, and ankle ; sole ; part of dor- sum of foot. i s E 41 Third sacral . . . Perineal muscles j ^ (erector penis, transver- salis perinei, accelerator urinse, &c.). Perineum, external genitals, "saddle-shaped" area of back of thigh. Fourth sacral . . . Bladder and rectum. CASE 33. Fracture of first lumbar vertebra Crush of conus medullaris. One of the least extensive lesions produced by injury to the lumbar cord is that found in the following case, recorded by Kirchhoff. 2 A man, aged thirty, fell sideways from a horse on to his nates. As a result of this accident, he was at first unable to walk, and was confined to bed for three months. During the first three weeks he had retention, and thereafter incontinence of urine, with cystitis. He suffered also from involuntary and un- conscious defsecation. After some nine months he grew gradually better, until he could remain on his legs all day, but there was no material change in the condition of his bladder and rectum. At the end of eighteen months he was seen by Kirchhoff. At that period he presented tenderness and some deformity over the first 1 Here, as elsewhere, the term "extensors of the ankle" is used in reference to the anterior muscles, i.e., the extensors in a morphological sense. 2 Arch, fiir Psychiatric, vol. xv. p. 607. I 1 2 SURGERY OF THE SPINAL CORD. lumbar spine. The walk was slow and straddling (weitbeiniy), motor and sensory power were preserved throughout the body, but all four limbs were weak. The patellar reflexes were a little exaggerated. With these symptoms he had loss of control over the bladder and rectum. After complete emptying of the former (by the catheter), urine was retained for some two hours, but incontinence then ensued. If the faeces were fluid, they could not be retained at all; but if solid, he could hold them until the bed-pan was brought. Cystitis was followed by pyelitis, secondary abscesses, and death. At the autopsy was found a crush of the first lumbar vertebra. The discs above and below it met in front, and the body was driven backwards in the form of a triangle, which projected about I cm., compressing the lower end of the cord some 3 cm. above the filum terminale. The conus medullaris was also forced to the right of the displaced bone. Microscopical examination showed de- generation of the conus medullaris and ascending degeneration of the cord, but no injury to the fibres of the cauda equina. Besides these changes, there were the ordinary appearances of pyelitis and metastatic abscesses. In the above case we find a practically uncomplicated lesion of the termination of the spinal cord, whose nerves appear to supply the bladder and rectum only. True, there would seem to have been originally some slight injury to other nerves going to the lower limbs, but the effect of this general pressure on the cauda was almost entirely transient, and the only definite result was paralysis of the sphincter ani and of the detrusor and sphincter vesicas, both doubtless due to the mischief done to the termination of the cord. That the detrusor was paralysed is shown by there being pure retention of urine for the first three weeks, followed by incontinence when partial recovery permitted of some return of function. It is impossible to derive any information as to the relative vertical arrangement of the reflex centres. Now the absence of any anaesthesia about the perineum, penis, or scrotum, and the negative evidence that there is no note of any interference with the sexual functions, such as would arise from paralysis of the muscles of this region, sufficiently indicate that the majority, at any rate, of the fibres of the pudic nerve had escaped injury, and that the other chief branches of the sacral plexus had done so is obvious. We are thus driven to localise the lesion, in this case, immediately above the fourth sacral nerve or its point of origin, because the pudic and the INJURIES OF THE LUMBO-SACRAL REGION. I 1 3 nerves for the lower limbs receive such large reinforcement from all the roots above this point, that we can hardly imagine a lesion involving the third sacral, and yet giving rise to such slight symptoms. For the present, therefore, we may assume this to be illustrative of a lesion of the fourth and fifth sacral and the coccygeal nerves only. The small patch of anaesthesia (in the region of the tip of the coccyx) and the paralysis of the levator ani, which might be expected to result from injury of the two latter branches, would readily escape notice. CASE 34. Fracture of last lumbar vertebra Compression of cauda equina ~by callus. Strikingly similar to the foregoing is the following case, which was treated in Mr. Whitehead's wards in the Manchester Infirmary. D. E., a collier, aged forty-nine, was at work in a coalpit towards the end of October 1885, and was standing upright when an unknown weight of coal fell from the roof, striking him across the back of the' hips, He became immediately paraplegic, and afterwards remained in bed, without, he said, undergoing any improvement, up tO' the date of his admission to the Infirmary, some seven weeks after the accident, viz., on December 24, 1885. On admission, he appeared very ill, and the whole body was much wasted, the muscles of the upper limbs being as atrophic as those of the lower, except that the nates had perhaps chiefly suffered. He presented no cerebral symptoms. The spine showed no deformity, and could not be said to be tender at any point, although there was vague soreness over the sacrum. He complained of severe neuralgic pains, shooting down the backs of the thighs and legs to the heels, and at times extending from the bladder to the end of the penis, or referred to the sacrum. Pressure on either sciatic nerve, between the tuber ischii and the great trochanter, caused intense pain. The bladder was much distended, and there was a constant dribbling flow of urine, accompanied by much pain, but he retained some power of voluntarily increasing the flow by great efforts. He was greatly troubled by constipation, and had no control over the passage of his faeces. Without support he could not stand at all, but, with very slight assistance, he could walk with a sprawling, hesitating gait, and in bed he could move his lower limbs in all directions. All the muscles reacted readily to the faradic current, and presented no abnormality with the galvanic ; tactile, thermal, and muscular sensibility were normal everywhere ; the super- H 114 SUEGERY OF THE SPINAL CORD. ficial reflexes were normal, the knee-jerks slightly exaggerated, but there was no ankle-clonus. The skin of the whole body was covered with a sour perspiration, and that over the sacrum was red and inflamed. The temperature was normal; pulse 78, full, regular, and rather compressible. Urine acid, clear, of sp. gr. IO2O, and without albumin. He suffered much from thirst. No inquiry was made as to the sexual functions. Treatment consisted in complete rest in the supine position, with periodic evacuation of the bladder. On the evening of December 3 I , a week after admission, the temperature, which had hitherto been normal, rose suddenly to 103.2, and it thereafter remained high. At the same time the urine became alkaline and foul, and he suffered from constant nausea and vomiting, with foul tongue. These symptoms were followed by fibrillar tremblings in the muscles of the trunk and limbs, by rapidly increasing and intense emaciation, obstinate in- somnia, foetid sweating, and a very frequent (iSo) intermittent pulse. On January 1 8 he became violently delirious, and lapsed into a " typhoid " condition, with a running uncountable pulse, and two days later he died. The post-mortem examination was made by Dr. Harris, then pathologist to the Infirmary, whose report states that on opening the spinal canal there was found on its anterior aspect, projecting from the posterior part of the body of the last lumbar or first sacral vertebra, a disc-shaped bony prominence about the size of a marble. Although no other signs of fracture were to be found, this was taken to be probably due to callus. This nodule com- pressed the entire cauda equina opposite to it that is, some 4^ inches below the conus medullaris through a vertical extent of about half an inch, the component nerves being united by a delicate and vascular newly-formed connective tissue. The spinal membranes themselves and the cord were healthy throughout, there being no meningeal thickening even opposite the bony nodule. Above and below the latter the nerves of the cauda equina presented no abnormality, nor was any change detected in the sciatic nerves, either with the naked eye or with the microscope. The bladder cavity was abnormally large, although not very markedly so, its walls of normal thickness, its mucous membrane pale and smooth, except at the posterior part, where there was a small recent hsemorrhage in the submucous tissue. It contained a large quantity of pale slightly turbid urine. The ureters were not dilated. Both kidneys were much enlarged the right weigh- ing nine, the left ten ounces ; their capsules peeled readily, but INJURIES OF THE LUMBO-SACRAL REGION. 1 I 5 were thickened, and throughout their substance were numerous minute abscesses, each surrounded by a dark zone of haemor- rhage ; the pelves were normal. The aortic valve of the heart was thickened and incompetent ; both this and the mitral valve showed evidences of recent endocarditis ; the walls of both ventri- cles were of normal consistency, but thickened, the entire heart weighing 13^ ounces. The other organs of the body were healthy. Here, then, we have a case in which the cauda equina was partially compressed about the level of the last lumbar vertebra. From this resulted severe neuralgia in the sciatic and pudic nerves, and weakness of some of the muscles of the lower limbs, but no complete paralysis and no anaesthesia of the limbs. Follow- ing the rule to which we have already referred, that the lowest branches of the cauda suffer most in a general pressure lesion, we find a complete paralysis of the sphincter ani and of the nervous mechanism of the bladder. The paralysis was here evidently due to interference with the peripheral fibres, and not with the nuclei. The power of expelling some urine by voluntary straining was probably due solely to action of the abdominal muscles. As in KirchhofFs case, there is a possible doubt whether (ignored on examination) the region between the coccyx and anus, usually sup- posed to be supplied by the coccygeal nerve, may not have presented a small patch of anaesthesia, but certainly there was no loss of sensation in the perineum or limbs. Hence, then, this case further indicates that the branches for the sphincter ani and the bladder muscles have a lower origin than those supplying the skin and muscles of the perineum. There are several points in the case not inquired into so fully as might be wished, due to the fact that in 1885 my attention had not been directed to the details of the subject. CASE 35. Injury to cauda equina (?) Paralysis of bladder and sphincter ani. On March 16, 1887, I saw, with Mr. George Thomas, of Bradford, T. 0., thirty years of age, who sustained an accident on December 29, 1886. On that date he was standing up in a cart, when a van ran into the latter from behind, throwing him out in such a way that he fell upon his back on the road, striking the lumbar region against the curbstone of the pave- ment. He was able to get up at once and to walk, but says that his legs felt stiff and trembled. Shortly afterwards he walked up some stairs to the top of a warehouse, and he drove home. I 1 6 SURGERY OF THE SPINAL CORD. On reaching his home he went to bed, and during the day the lower limbs became partially paralysed, as they have since re- mained. From that time until I saw him he had been bedridden, but had undergone little or no change except general loss of flesh from confinement. At first he had severe pain in the lumbar region, but in a few weeks this diminished, and in March 1887 he had only some aching, mainly when sitting up. On examination, he was found to present partial paralysis of the lower limbs. He could get out of bed and across the room by means of supports, but could not stand if unaided. When lying down, he moved the limbs at every joint, but only with great effort and to no very great extent. There was no marked wasting of the muscles. He stated that ten years previously he had had a fall, ever since which his right foot had " dropped a little." He believed the weakness of the limbs to be increasing. There was nowhere any anaesthesia. The knee-jerk and ankle- clonus were much exaggerated, the plantar reflex normal, the cre- masteric absent. He complained of his legs occasionally "jump- ing " at night. His urine ran away from him almost constantly, but was not foetid ; bladder dulness extended from the pubes to the umbilicus. He knew when he was about to pass his feeces, but could not retain them, and must at once obey the call to stool. He had no priapism, nor any trace of trophic lesions, and erections of the penis occurred as usual. Locally there was no deformity, but some tenderness of the spine, most marked opposite the level of the posterior superior iliac spines. The general health had remained fairly good. Mr. Thomas has kindly endeavoured to obtain some information for me as to the subsequent progress of this case, but has been unable to hear anything very definite. The bladder and rectal symptoms appear to have undergone no improvement, but the paresis passed off, and no further troubles have supervened. In the summer of 1888 he was farming near Chester, and "looked fairly well." Hence in this case also the entire cauda equina would seern to have been temporarily injured as regards the motor power of its nerves, but the only permanent trouble was, as in Kirchhoff's case, the interference with the bladder and rectum, supplied by the lowest roots. The case is, however, not satisfactory evidence, as the lesion may have been a slight transverse myelitis in the upper lumbar region. We may next refer to a group of cases in which the above- described symptoms were present, but were accompanied by other phenomena, indicating a somewhat higher lesion. INJURIES OF THE LUM BO-SACRAL REGION. 117 CASE 3 6. Injury of the, cauda equina involving the third sacral nerves. Huber 1 reports the following case : A man, aged twenty-four, fell some six yards on to a paved street, alighting in a sitting position. He immediately felt great pain in both tubera ischiorum, in the lumbar region, over the sacrum and along both sciatic nerves, and he could not stand. From the moment of the accident he had retention of urine, with involuntary evacuation of faeces, accompanied by obstinate con- stipation. He could hardly move his legs, and had a feeling of numbness in them. The sacral and gluteal regions were very tender. After about a month he could stand and walk, and at that time he came under Huber's observation. He then com- plained of retention of urine, inconti- nence of fasces, slight weakness of both lower limbs, and numbness in the soles of the feet. Great flexion of the hips caused pain from the exit of the sciatic to the middle of the thighs. There was no paralysis of either limb, and the reflexes (superficial and deep) were all normal. He was found to have anaesthesia about the anus and seat, in the perineum, scrotum, and penis, and on part of the posterior sur- face of the upper part of the thighs. The boundaries of this region were not sharply denned, and will most readily be understood from the accompanying representation of Huber's diagram (tig. 18), which by the degree of shading indicates the varying intensity of the anaesthesia. Although the scrotum was anaesthetic, the testes were not. There was very dull sensation on passing the catheter or introducing the finger into and pressing upon the rectum. An ill-defined sensation was noticed before fasces were passed. The walk was normal and without pain. He could bend the back, but on bending the knees had slight pain in the calves. There was no deformity of the back. Some three 1 Wiener medizini*che Wochenschrift, 1888, Nos. 39 and 40. FIG. 18. n8 SURGERY OF THE SPINAL CORD. months after the accident it became unnecessary to use the catheter, as the patient could by strong pressure on the bladder cause the urine to flow slowly. He had sometimes partial erec- tions of the penis not, he thought, sufficient for copulation and two or three times there was an escape of semen with slight voluptuous sensation, there being no ejaculation, but only a slow escape from the urethra. Huber's diagnosis is intra-meningeal hasmorrhage below the lumbar enlargement, which for a short time compressed the cord itself, causing the paralysis, and is still pressing on the roots of the pudic and coccygeal nerves, as well as on the lower roots of the sciatic nerve, which furnish the small sciatic branch, the latter being less affected than the pudic and coccygeal. There was no evidence of fracture, and the immediate onset and other symptoms negative myelitis. CASE 37. Injury in lumbar region, involving the third sacral roots. A very similar case is related by Bernhardt : * On January 10 a patient fell on to his seat from the second floor of a building, and, not losing consciousness, complained only of pain in the back and retention of urine. On the following day he had to be catheterised, and he passed his fasces in- voluntarily and unconsciously. Nine days later he could stand alone, but had pain from about the seventh to the twelfth dorsal vertebra, where there was some swelling and tenderness. He had still retention of urine and unconscious defaecation. There was no paralysis of the lower limbs, the superficial and deep reflexes were normal, and, except in one region, sensation to all varieties of impression was normal. Anaes- thesia was, however, complete in the peri- neum, scrotum (but he could feel pressure on the testicles), penis, over the lower part of the sacrum and coccyx, and thence out- wards for about a hand's-breadth, as well as down a strip on the inner and posterior aspect of the thighs, indicated in the accom- 1 Berliner Idinisclie Wochcnschrift August 6, 1888. Fio. 19. INJURIES OF THE LUMBOSACRAL REGION. I 1 9 panying figure (fig. 1 9). The patient continued to use the catheter, but had no sensation of the bladder being full. He could feel by abdominal movements when he passed fseces, but did not feel their course through the rectum or anus. He had sometimes erec- tions, and once a pollution, and in February he performed coitus. By May he could sometimes pass a little urine, but never com- pletely emptied the bladder, and if he was not catheterised the latter would ultimately become over-full, and urine would flow. On the 1 2th of May he found that on coitus the act was normally performed, except that the semen was retained in the urethra, and only escaped in drops some time afterwards. An electric current was not felt in the perineum, urethra, or rectum, nor could any contractions be felt by the finger in the levator ani or perineal muscles. After continued electrisation of these parts there was some improvement in the power of passing urine and retaining faeces. What the exact nature of the lesion in this case might be could not be ascertained without a post-mortem examination. Bernhardt insists mainly on the fact that while the nervous supply to the bladder and rectum was almost absolutely de- stroyed, that of the genital system was but little affected. The nervi erigentes were uninjured, and so perhaps was the nerve to the erector penis ; sexual pleasure was also retained, but impo- tence resulted from the loss of expulsive power that is, from paralysis of the accelerator urinae and transversalis perinei muscles. Two other cases, recently published by Oppenheim and by Osier, still further illustrate this group of symptoms. CASE 38. 1 Fracture of first lumbar vertebra Crush of cord about level of origin of third sacral roots. A man, aged twenty-four, fell from the second floor of a house on to his sacrum. After a brief period of unconsciousness, he noticed numbness and paralysis of both lower limbs, both of which symptoms rapidly passed away. He had immediate reten- tion, followed by complete incontinence of urine and faBces, with unconsciousness of their passage. Neither erections nor passage of semen ever occurred after the injury. At the region of the first and second lumbar spinous processes was some angular curvature. Of the muscles of the lower limbs, those of the calf 1 Oppenheim, Archiv filr Psychiatric, Baud xx. Heft I. I2O SURGERY OF THE SPIXAL CORD. only showed very slight weakness ; otherwise there was no loss of power, and no atrophy or electrical change. The knee-jerk was exaggerated, but there was no ankle-clonus. Anaesthesia affected the region of the anus, buttocks, perineum, scrotum, and penis, and a small strip on the inner and posterior aspect of the upper part of the thighs: above, it was limited by a line about half-way down the sacrum, and externally it extended to midway between the tuber ischii and great trochanter. Cystitis and fever supervened, the patient dying about three months and a half after the injury. At the post-mortem examination was found a fracture of the first lumbar vertebra. The terminal portion of the conus medul- laris was compressed, showing the histological appearances of myelitis with haemorrhages, and the lowest sacral roots were degenerated. The remaining roots of the cauda equina were almost absolutely normal. CASE 39. 1 Injury in lumbar region involving third sacral roots. A man, aged forty-seven, fell from a bridge into a sitting posture, and at first sus- tained paralysis of the legs, bladder, and rectum, the paralysis of the lower limbs passing off gradually. Six- teen years after the injury he had slight weakness and atrophy of the left lower limb. The spine presented no local signs of injury. He had no control over the bladder and rectum, and was impotent. The gluteal and cremasteric re- flexes and the knee-jerk remained. Anaesthesia is represented in the annexed copies of Osier's diagrams (figs. 2O and 2i), and affected the lower gluteal regions, posterior aspects of the thighs, perineum, scrotum, and penis as far as its root. The urethra was also insensitive. 1 Osier, Medical News, December 15, 1888. FIG. 20. FIG. 21. INJURIES OF THE LUMBO-SACRAL REGION. 121 It will thus be seen that, just as our three first cases represent a group in which the injury is of the slightest nature, and pro- bably affects only the terminal roots of the cord, so also the last four form another group in which we have the same vesical and rectal troubles plus paralysis (in the male) of the ejacula- torates seminis, with anaesthesia of the perineum and genital organs and of a patch in the thighs, which, from the obvious coincidence with those parts of the thigh which come first into contact with a small saddle, we may perhaps call the " saddle- shaped " type. We find then in our second group destruction of function of the fourth and fifth sacral and of the coccygeal nerves, together with anaesthesia of the entire cutaneous distribution of the pudic nerve, and of part of that of the small sciatic (especially its inferior gluteal branch), and paralysis of some, perhaps all, of the muscular branches of the pudic (running to the transversalis perinei, erector penis, accelerator urinse, and compressor urethrae). May we not then venture to assume that this second group of cases represents the effects of injury to the third sacral and subjacent nerves, the third thus being the root which supplies the bulk of the pudic trunk, and a portion of the sciatic, devoted apparently to such of the cutaneous distribution of the small sciatic nerve, as has been fully described ? In these cases we find also an interesting condition of the nervi erigentes. In Case 36 these nerves were apparently par- tially paralysed ; in Case 37 they had entirely escaped injury ; and in Case 38 they were totally paralysed (in Case 39 we have no precise information). Dr. Gaskell has localised these nerves in the second and third sacral roots, a conclusion which perfectly explains the varying extent of the injury done to them in a lesion of the third. Thus far we have referred only to injuries of the extreme lower roots of the sacral plexus, but owing to the obscurity of the few recorded cases of injury or disease immediately above this region, it will perhaps be better now to turn to the upper limits of the lumbar plexus, and to trace downwards the connecting links which lead us to the previous groups. I have no instance of a lesion immediately below the first lumbar root, but it is not necessary to adduce evidence that that root supplies the ilio- hypogastric and ilio-inguinal nerves. To what extent it provides fibres of the genito-crural I am unable to say. 122 SURGERY OF THE SPINAL CORD. CASE 40. Dislocation of last dorsal vertebra Paralysis below second lumbar nerve-roots. T. H. was admitted into the Manchester Royal Infirmary, under the care of Mr. Hardie, on January 16, 1888. He was a labourer, aged thirty-nine, and was loading a cart when a bale of cloth fell upon his shoulders, doubling him up. For the first few minutes he was unconscious, and then found that he had lost both motion and sensation in the lower limbs. On admission, he complained of pain in the lower part of the back and the right side of the PIG. FIG. 23. chest, pain being also caused in the lumbar region of the spine on pressing down the shoulders. Two of the lower spinous processes were somewhat prominent. The lower limbs were entirely para- lysed, but there was no affection of the trunk or upper extre- mities. He had anaesthesia of the lower limbs, with the following boundaries : In front, sensation extended accurately to the line of Poupart's ligament, except that on the outer side of the left thigh there was a patch of sensation extending downwards, and of about the size and shape of the hand with the fingers held down- wards. On the right side was a patch of similar shape, but about twice the above size, and extending more to the front of the thigh. INJURIES OF THE LUMBO- SACRAL REGION. 12 The penis and scrotum were also anaesthetic, except at the upper part of the latter, i.e., in the distribution of the ilio-inguinal nerve. Behind, anaesthesia was limited by a line extending from the upper part of the great trochanter to the posterior superior spine of the ilium, and thence to the middle line. The annexed diagrams best illustrate the boundaries of the affected region (figs. 22, 23). 1 The plantar and cremasteric reflexes were absent, as were also the knee-jerks. The penis was turgid, urine was retained, and had to be drawn off by the catheter; it had a sp. gr. of 1014, was acid, and contained no albumin or sugar, but gave a deposit of phosphates. The pulse was feeble, 96 per minute ; temperature 99 ; respiration somewhat abdominal, with bronchitis, due to a cold which had existed before the accident. Three days after admission the urine became alkaline and foetid and con- tained blood, which was present for a day or two only, and was then replaced by pus. For several weeks thereafter no change of importance occurred, and the general condition improved, the bronchitis passing off, and the cystitis varying in severity from time to time. Wasting of the lower limbs came on gradually, and two months after the accident their muscles were all found to be insensitive to the faradic current. The feet also became somewhat cede- matous. Turgidity of the penis still continued, but appeared to be due to irritation from use of the catheter. About this time the patient complained of great loss of sight in the right eye, but repeated examinations made both by Dr. Little and myself failed to show any abnormality, either organic or functional, with the exception of myopia. During the next month this symptom gradually improved. On May i6th, when I last saw him, he had been very ill for several days, with much vomiting, and was very thin ; his nervous symptoms presented no change of importance, the paralysis and anaesthesia being the same as on admission. The urine constantly dribbled away from him, was very foetid, and contained much pus. 1 In fig. 22 the unshaded or sensitive area is carried too low on the left side. FIG. 24. Fracture of first lumbar and dislocation of last dorsal vertebra. 124 SURGERY OF THE SPINAL CORD. Four days later he died exhausted. The temperature throughout the case was usually slightly raised. The post-mortem examination was made by my clerk, Mr. Hopkinson, who removed several of the vertebrae, from a sagittal section of which is taken the annexed sketch (fig. 24). The latter shows a fracture of the first lumbar vertebra with disloca- tion forwards of the last dorsal. The lower part of the spinal cord and the trunks of the cauda equina were, after death, not markedly compressed by the projection backwards of the former bone. In the bodies of both vertebrae were changes due to chronic osteo- myelitis, but there was no trace of callus. CASE 4 1 . Dislocation of last dorsal vertebra Paralysis beloiv second lumbar nerve-roots. L. L., aged thirty-seven, a collier, was admitted to the Man- chester Royal Infirmary, under the care of Mr. Heath, on Feb- ruary 21, 1888. Shortly before admission he had been working in the pit when a portion of the roof, of which he judged the weight to be about two tons, fell upon him, striking his left shoulder and bending him forwards, so as to double him up. He was immediately paralysed, but did not lose consciousness. On the following day, when I examined him, he complained of pain in the belly and back, and of loss of power and sensation in the lower limbs. He had also the effects of a severe bruise on the left shoulder. Over the lower dorsal and upper lumbar region was found a somewhat extensive depression, but the exact outline of the bones was masked by effused blood. In this region he complained of great pain and tenderness, but he had no pain on jerking the spine from above. The lower limbs were abso- lutely paralysed, but the thoracic and abdominal muscles as well as those of the upper limbs had escaped injury. The limitation of anaesthesia was not very distinct ; " it appeared to extend over all nerves below the last dorsal, except that in the distribution of the ilio-inguinal, ilio-hypogastric, genito-crural and external cutaneous there remained some vague sensation." About the level of the ilio-hypogastric and last dorsal was slight hyperaes- thesia. The knee-jerk and the plantar and cremasteric reflexes were absent. All these symptoms were symmetrical. The urine, which was retained, and had to be withdrawn by the catheter, had a sp. gr. of 1030, was loaded with urates, contained a little albumin, and gave a very well-marked sugar reaction. INJURIES OF THE LUMBOSACRAL REGION. The penis was slightly turgid. He had had some bronchitis before the accident, and had at this time a bad cough, the chest move- ments being feeble. Temperature, 100; pulse, 80; pupils, somewhat dilated. On the following day the line of demarcation of the anaesthesia was better marked, and its distribution was found to be on both sides almost identical with that represented on the right limb in figs. 22 and 23. The urine contained less albumin (there being a scarcely perceptible trace), and no sugar. For some days there was no marked change. The cough im- proved slightly. The urine became alkaline and foetid, and on February 28 contained swarms of micro- cocci, mostly in pairs and small chains, but no pus. The anaesthesia extended an inch or so upwards on the abdomen, with a hypersesthetic band above it. On March 2 it had reached to a line 2^ inches above the umbilicus, but was by no means complete for some distance below this level. The bowels were at first obstinately confined, but after the administration of croton oil on February 27, faeces were passed involuntarily. Pain round the abdomen was so great as to require frequent use of morphia and belladonna stupes. The temperature became daily a little higher, reaching after February 27 to about 103, with no marked variations. On March 3 he was obviously sinking ; his cough was very troublesome, the bronchial passages much obstructed, and the temperature fell three degrees. On March 4, the twelfth day, he died exhausted. At the post-mortem examination we found the disc between the twelfth dorsal and first lumbar vertebrae ruptured, and the anterior part of the latter vertebra broken away obliquely, as shown in the accompanying engraving (fig. 25). The spines of these two vertebrae were separated behind, owing to the twisting forwards of the last dorsal, but there was not at the time of the autopsy any displacement sufficient to narrow the spinal canal. The pedicles of the twelfth dorsal vertebra were also broken across, but without displacement of its arch, and its articular processes were separated from those of the first lumbar. The dura mater was intact, and the cord and cauda equina not compressed, nor FIG. 25. Fracture of first lumbar ami dislocation ot last dorsal ver- tebra. 126 SURGERY OF THE SPINAL CORD. was there any haemorrhage into the spinal canal. The cord was, however, quite soft at the seat of the lesion, and for some two inches above it. In these two cases we have complete paralysis of the crural plexus, except that certain sensory nerves have escaped. The skin-area thus spared is represented by figs. 22 and 23, and it will be found that the nerves not interfered with are the ilio- hypogastric and ilio-inguinal, which undoubtedly arise from the first lumbar root ; together with a part of the distribution of the genito-crural, arising from the first and second lumbar, and of the external cutaneous, which arises from the second and third lumbar. 1 The lesion in each case may, therefore, probably be sup- posed to be beneath the second lumbar nerve, which will perfectly explain the sensory effects. We should expect the testicles also to be sensitive, owing to the distribution to them of the genital branches of the genito-crural, but, unfortunately, this point was not investigated in either case. They have, however, been found to retain sensation in several cases of injury at slightly lower levels. There is no evidence that any muscles supplied by the plexus escaped paralysis, it being impossible to demonstrate the functions of the nerve to the cremaster, except by the reflex, which is here annihilated by the anaesthesia. The turgidity of the penis noticed in both cases is merely the semi-distended condition seen in most spinal injuries, and is quite different from the distension of erection such as may occur when the injury is below the level of the nervi erigentes. We are thus brought downwards to the level of origin of the third lumbar nerve-roots. Below this region I have no cases to offer in which the differentiation of roots was produced by a localised crush of the cord, but if we grant the original postulate that in crushes of the cauda equina the most i njured roots are those of lowest origin, we obtain much information from the cases related in the previous chapter. Thus in Case 29 the distribution of the anaesthesia indicates a complete paralysis of the entire sciatic nerve, and of all the nerve- roots inferior to those from which it arises. Hence the muscles partially paralysed are presumably supplied by the third and fourth lumbar roots, the chief tributaries of the anterior crural. These muscles are, in the order of increasing severity of paralysis, as follows : 1 In referring to the distribution of sensory nerves, I have used Mr. Wagstaffe's edition of Heiberg's " Atlas " (London, 1885). INJURIES OF THE LUMBOSACRAL REGION. I2/ 1 . Flexors of the thigh : psoas, iliacus, with assistance of sartorius and rectus. 2. Adductors of the thigh and extensors of the knee : adductor group, rectus and quadriceps femoris. 3. Abductors of the thigh : tensor fasciae and fibres of the glutei. If, again, we compare the relative strength of the muscles in Case 32, in which the lesion was similar, we have : 1 . Adductors of thigh. 2. Flexors and extensors of thigh. 3 . Extensors of knee. 4. Abductors of thigh. In both cases, then, we find the adductors and flexors of the thigh retaining more power than the extensors of the knee or abductors of the thigh, so that we may localise the nuclei of the adductors and ilio-psoas higher than those of the quadriceps, tensor fasciae, and gluteus maxinaus. The considerable power retained in the extensors of the thigh in Case 32, I can having regard to the otherwise demonstrated interference with the func- tions of the sciatic only regard as probably due to an error of observation. It is an extremely difficult matter to estimate the comparative contractile power of the muscles of the lower limb, and in this instance, as the patient could only be satisfactorily examined when lying on his back, the action of gravity would assist the extensors of the thigh and oppose both the flexors of the thigh and extensors of the knee. The cases tabulated on pp. 98, 100, bear out this arrangement, as do Cases 30 and 31, the diagrams of the distribution of anass- thesia in the two latter illustrating the sensory distribution of nerve-roots below the fourth lumbar. On the basis of the above results, I would then assign to the third and fourth lumbar roots the innervation of the adductors, flexors, and abductors of the hip-joint, and of the extensors of the knee-joint, and would place the adductors and flexors of the thigh at a higher level than the other muscles supplied from the anterior crural, so that probably the third" lumbar root sup- plies the adductors and ilio-psoas, the fourth lumbar the rectus, quadriceps, and tensor fascia femoris. The position of the sartorius is perhaps determined by a case of spinal injury recorded by M'Donnell, 1 in which the muscles of the lower limb were paralysed, with the exception of those of the " front of the thigh," which were paretic only, and of the sartorius, which appeared to have entirely escaped injury. Hence it would 1 Dublin Quarterly Journal of Medical Science, vol. xlii. Supra, p. 102, Case H. 128 SURGERY OF THE SPINAL CORD. appear that the spinal nuclei for this muscle must be assigned a high position in the region of origin of the third lumbar root. The sensory distribution of the third and fourth lumbar roots is best illustrated by the diagrams of retained sensation in Cases 30 and 31, but I have no facts which assist us to differentiate the two roots satisfactorily. In Case 44, recorded below, the method of disappearance of the anassthesia would seem to indicate that the plexus patellee (derived from the obturator nerve), and the long saphenous, arise lower than the middle and internal cutaneous branches of the anterior crural. The cremasteric reflex is retained when the third and fourth lumbar roots escape paralysis, but lost when the lesion extends above their level of origin. Passing on now to the consideration of roots below the fourth lumbar, we find that in Case 32, where these inferior roots had partially escaped injury, the muscles of the posterior aspect of the thigh retained more power and recovered much more thoroughly than those of the leg and buttock. We are thus led to regard the former as supplied from a higher point in the cord, and we may assign them to the fifth lumbar root, which gives a very large branch to the sciatic. This would leave us with the first and second sacral roots for the supply of the glutei and leg-muscles. Unfortunately the evidence available to enable us thus to split up the functions of these three great tributaries of the sciatic is very scanty, but, such as it is, it bears out the above view. CASE 43. Dislocation of fifth lumbar vertebra Injury to sacral nerve-roots. Kahler J relates the case of a young man who had fallen a distance of about nine yards, probably on to the buttocks. The lower limbs were at first completely paralysed and anaesthetic, but a certain amount of improvement shortly ensued, so that in seven months he could walk with crutches. After that period there was no further change. When examined after the lapse of two years, the spine showed marked lordosis, the second lumbar spinous process was in its normal position, the third was depressed, and the fourth still more so, the fifth being so deeply seated that it could not be felt. Various details given in the original paper show clearly that the fifth lumbar 1 Prayer medic. Wochenschrift, 1882, Nos. 35, 36, and 37. INJURIES OF THE LUMBO-SACRAL REGION. 129 vertebra was dislocated forwards on the sacrum. The patient had no control over the bladder, which was much distended, and emptied itself involuntarily. Defecation was also involun- tary. In the lower limbs the adductors of the thigh and the quadriceps were well developed, the tensor fascise, posterior thigh-muscles and glutei were much wasted, as were all muscles below the knee, those of the calf being the best developed of the latter. Both feet were pointed. Adduction and flexion of the hip were powerfully performed ; extension, and especially abduc- tion, feebly so. Exten- sion of the knee was well performed; flexion almost impossible. Ac- tive movements of the foot and toes were totally paralysed. The peroneus longus and brevis, the tibialis anticus, and the ex- tensor communis digi- torum presented the reaction of degenera- tion, but the rest of the above-mentioned muscles (including the glutei and gastroc- nemii) did not. The knee-jerks were re- tained. Slight ankle- FIGS. 26 and 27. T ne hypersesthetic area is shaded with crosses ; the region of total anaesthesia with lines ; in the area indicated by large dots there was loss of the senses of pain and of temperature only ; ill that of the small dots, loss of temperature sense. clonus could be elicited, but the plantar reflex was lost. The sensory deficiency is best in- dicated by a copy of Kahler's diagrams (Figs. 26 and 27). The temperature of the lower limbs was the same as that of the rest of the body. Over the gluteal region was a bed-sore, but no other trophic changes presented themselves. Kahler regards this as an instance of injury to the fifth, lumbar roots, at their point of exit between the last lumbar vertebra and the sacrum ; but it would appear to the writer to represent rather a crush of the cauda equina at this level. The distribution of the anaesthesia corresponds to an injury involving the pudic nerves and the greater part of the area supplied by the sciatics> and the I3O SURGERY OF THE SPINAL CORD. affection of the bladder and rectum also show the lower roots to have been affected. Taking this view, we can arrange the muscles of the limb in the order in which they suffered, i.e., probably in the order, from above downwards, of the origin of their nerve-fibres, thus : 1 . The adductors and flexors of the thigh uninjured. 2. Extensors and abductors of the thigh weakened and wasted. 1 3. Glutei and gastrocnemeii paralysed and much atrophied. 4. Peronei, extensors of ankle (and intrinsic muscles of foot ?) entirely paralysed, and presenting the reaction of degeneration. This supposition is borne out by the ultimate condition of Case 32, in which, after recovery of the other muscles supplied by the sciatic, those moving the ankles and toes remained para- lysed, and by Case 30, where the sensory paralysis affected the sciatic and pudic nerves, and the motor paralysis chiefly the muscles supplied by the pudic nerve and those about the ankle. Further confirmation is derived from the following : CASE 44. Injury to the lower (? second} sacral nerve-roots. This case was kindly shown to me by Dr. Jones, of Wath- upon-Dearne. The patient was a collier, aged forty-six. On March 15, 1887, he received an injury to his spine, being doubled forwards by a weight falling on to his back. His lower limbs were paralysed for sixteen weeks, and he had " very little " feeling in them. During the first fortnight his urine had to be drawn off by the catheter. When I saw him, eighteen months after the accident, he com- plained of pain and a burning sensation in the hips. He walked with the knees bent, throwing his weight on to the heels, and he could not raise the toes of the left foot from the ground when the foot was kept firm, those of the right being moved with difficulty only. He had nowhere any anaesthesia. The plantar reflex was lost, the cremasteric retained on both sides, and the knee-jerks were absent. He required much straining to pass water, but could do so by his own efforts. There was no rectal trouble, and coitus was, he said, normally performed. The spinous 1 The nerves to these muscles pass out of the vertebral canal above the level of the lesion, but there are several obvious explanations of an upwards extension of the pressure upon the cauda equina. INJURIES OF THE LUMBO-SACRAL REGION. 13! process of one of the lumbar vertebrae, apparently the first, was displaced about half an inch to the right of the middle line. Here the only traces of paralysis were found in the extensors of the toes and in the wall of the bladder, and there was no anaesthesia. In the following the paralysis was almost universal in the lumbo-sacral plexus, but the ansesthesia produced by injury to the lower nerve-roots of the sciatic is well indicated. CASE 4 5 . Dislocation of last dorsal vertebra Paraplegia Partial anaesthesia Trephining. J. M., aged twenty-eight, a pattern-maker, was admitted to Mr. Jones's wards on March 9, 1888. A few minutes before he was brought in, some iron plates, which he estimated to weigh about 10 cwts., had fallen on to his shoulders, bending him forwards. He resisted their weight, but was gradually forced down until the plates were held up by some bystanders, just before he came to the ground. He was at once deprived of all power of motion and sensation in the lower limbs. On admission, there was found a circumscribed swelling over the lower dorsal region, one of the spinous processes being unusually prominent, deflected about an inch to the left side, and movable, but without crepitus. Chloroform was administered, and traction made upon the thighs, with counter-extension from the axillse and lateral movement of the pelvis, first to the left and then to the right side. By this means the line of the spinous processes was rendered straight, and pads and a bandage were applied to keep it so. The patient was then placed on a water-bed. On the following day, when I first saw him, the man com- plained of pain in the lower part of the back and abdomen, and in the upper part of the front of the thighs. No pain resulted from vertical jarring of the spine. Owing to the bandages, the spine itself was inaccessible. The lower limbs were completely paralysed, but the muscles of the abdomen, thorax, and upper limbs had escaped. The plantar and cremasteric reflexes and the knee-jerk were absent. Anesthesia extended over the front of the lower limbs to as high as a point two inches above the knee-joint, the boundary- line being concave downwards, and lower on the inner than on the outer sides of the knees, as in the annexed diagram. 132 SURGERY OF THE SPIXAL CORD. Fio. 28. Anterior aspect of right knee of J. M., showing boun- dary of anaes- thesia. In front of the thighs there was some hyperalgesia. From the wish not to disturb the patient, to whom the slightest move- ment caused great pain, the posterior aspects of the lower limbs were not examined. The urine was retained, had a specific gravity of 1026, and was faintly acid, containing no de- posit, but a mucous cloud, and traces of albumen, but no sugar. The penis was not turgid. The axillary temperature was 99, and remained near the normal throughout the progress of the case. During the next few days the hypersesthesia of the front of the thighs disappeared. Faeces were passed involuntarily and unconsciously. The muscles of the lower limbs became very tense, and vague sensibility was elicited by deep pressure on the legs. On the fourth day a small bulla formed on the right heel. On the sixth, the urine became ammoniacal and purulent, and on the eighth incontinence ensued. That the latter was not due to retention only was shown by the absence of defined bladder dul- ness, and by the fact that dribbling continued even immediately after the use of the catheter. By the twelfth day returning sensation had extended down- wards to below the patella in front of the lower limbs, but the entire posterior surfaces of both thighs as well as of the legs were now found to be anassthetic. The bnlla on the heel had healed up again. On April I 5 i.e., thirty-seven days after the accident the condition was as follows : The lower limbs were still completely paralysed and a good deal wasted. Their muscles all presented the partial reaction of degeneration, giving no response to the faradic current, but reacting more readily to the kathodal than to the anodal closing shock. The plantar reflex and knee-jerk were absent, the cremasteric reflex normal, and the epigastric very lively. The limits of sensory affection were not very well defined, but there was slight hypenesthesia and hyperalgesia, beginning about one inch below the umbilicus, and extending to immediately below the knees in front. Below this area was anaesthesia. Here the limit was ^-shaped, with the apex upwards, and reaching to a little below the patella, sensibility extending about half way down the inner side of each leg, and to a much less extent on the outer side. Behind there was very obscure sensation of the outer side of the gluteal region and back of the thighs and INJURIES OF THE LUMBO-SACKAL REGION. 133 legs, but the inner parts of the gluteal region, the perineum, scrotum, and penis, presented complete superficial anaesthesia. Deep pressure elicited vague sensation everywhere. The testes were as sensitive as usual. Observations with the sethesiometer yielded the following results : Anterior aspect of R. thigh, two points placed longitudinally felt at a distance of 4^in. L. Posterio R. L. aspect of R. L. R. L. transversely longitudinally transversely ifm. over 5^it over 3in. over 5^ii; over 3iii. [The instrument would not measure beyond 5^ inches, and on the backs of the thighs, when placed transversely, the points could not be separated more than three inches without passing beyond the confines of the sciatic nerve to those of the anterior crural and external cutaneous, upon doing which the}- were imme- diately distinguished. Great pressure was required over the backs of the thighs to make the instrument felt at all, and probably at no distance could the two points have been distinguished.] We may then sum up these observations by saying that (i.) Absolute ansesthesia affected the inner part of the gluteal region and postero-internal aspect of the thigh, the perineum, penis, and scrotum, and the lower branches of the sciatic nerve, as in- dicated by the heavy shading in the annexed diagrams (figs. 29 and 30); (2.) Somewhat less insensitive was the remainder of the region supplied by the large and small sciatic nerves ; and (3.) Sensation was still more perfect in the distribution of the obturator, the anterior crural, with its long saphenous branch, and the external cutaneous nerve ; but (4.) At an earlier period (that indicated in fig. 28) the plexus patellas of the obturator nerve was anaesthetic. At this same period also we found the skin of the lower limbs rough and dry, yielding, on slight scratching, a well-marked hyper- asmic line. About a fortnight previous to this date the patient said he had had an erection, and possibly he might have had a second, but there had been no sexual desire. His bladder was beginning to regain retentive power, and he could hold his urine for some two hours at a time, then passing it involuntarily, but not unconsciously. The faeces were still passed involuntarily and unconsciously. There was no affection of the optic discs. The back presented no pain or tenderness, the spinous processes were not displaced laterally, but that of the first lumbar vertebra was markedly prominent posteriorly, there being depression of those above it. 134 SURGERY OF THE SPINAL CORD. About May 8 the patient began to suffer occasionally from a sensation of cramps (unaccompanied by movement) and from shooting pains in the lower limbs ; and about May 26 he ac- quired slight power of voluntarily contracting the anterior thigh- muscles. The cystitis gradually improved, and the general health remained good. From this time there was practically no improvement beyond a very slight gain in cutaneous sensibility, appreciable only by measurements with the sesthesiometer, and it was now decided FIG. 29. FIG. 30. to trephine the spine, an operation which was performed by Mr. Jones on July 14, 1888, eighteen weeks after the injury. The patient having been chloroformed, was turned upon his face, and an incision was made, some five inches in length, to the left side of the spine, and with its centre opposite the projecting spinous process of the first lumbar vertebra. From both ends of this, other incisions were carried at right angles across the spine, and a rectangular flap of skin and subcutaneous tissue was thus raised. By means of the knife the vertebral muscles were cleared and then held aside, exposing the arch of the first lumbar verte- INJURIES OF THE LUMBO-SACHAL 11EGIOX. 135 bra, which was removed with bone-forceps, so as to lay bare the dura mater. The latter appeared to be healthy, although pro- truding somewhat backwards, but between the arches of the first lumbar and last dorsal vertebrae it was compressed by a mass of soft cicatricial tissue. As much as possible of this tissue was removed, together with the whole of the arch of the last dorsal vertebra, and the theca was then found to be so much flattened that its contents appeared to have been quite cut across. Im- mediately above this region the dura mater bulged slightly, and a small spicule of bone having penetrated it, some cerebro-spinal fluid escaped. All pressure on the theca being now removed, the skin flap was replaced and sutured, a drainage tube having been first inserted in the deepest part of the wound. The sur- faces were dusted with powdered boracic acid, and dressed with iodoform and sublimated wood-wool pads. No spray was used. On the day after the operation the temperature rose to IOO, and there was a good deal of shock, with much pain in the back. These symptoms, however, passed off in a i'ew days, no accident supervening, and the pain soon subsiding. On the fourteenth day the wound was healed. Although the general health continued good, there was unfor- tunately no marked improvement after the operation. The ante- rior thigh-muscles appeared to gain a little in power, and the anaesthesia of the lower limbs diminished to some extent, but these changes were only very slow and very slight. On October 10 the patient was sent to the Convalescent Hospital at Cheadle, where he remained for some time longer, but whence he was finally discharged without marked relief. A point of some importance in the above case is the limit of the anaesthesia on the front of the limb at an early period, as shown in fig. 28. It indicates that, of the region already de- scribed as being supplied by the anterior crural and obturator nerves (third and fourth lumbar roots), the lower portion is sup- plied from the lower root. Finally, the two following records, although of old date, de- scribe tolerably clearly the results of an injury affecting chiefly the lower roots of the sciatic trunk. 136 SURGERY OF THE SPINAL CORD. CASE 46. Fracture of first lumbar vertebra Paralysis and anaesthesia involving second sacral roots. Cruveilhier 1 mentions the case of a woman, aged thirty-five, who, having sustained a fall of twelve feet, was rendered unable to walk, in which condition she was seen at the Salpetriere three months later. She had then " incomplete power " in the muscles of her legs and thighs, with involuntary defgecation and micturition. Sensation was lost in the feet as high as the malleoli, and was obtuse above this point, but improved higher up the limb. The toes were strongly flexed on the metatarsi, and the feet extended on the legs. At the autopsy was found a crush of the first lumbar vertebra, with a bony projection about its centre com- pressing the spinal cord, which was pale and degenerated. The cauda equina had escaped injury. Here the paralysis appears to have chiefly affected the exten- sors of the ankle and toes, the posterior leg-muscles, by their uncontrolled contraction, giving rise to the deformity : at the same time there was anaesthesia in the region which previous cases have led us to regard as that of the distribution of the second sacral nerve-roots. CASE 47. Fracture of first lumbar vertebra Paraplegia Anaesthesia involving second sacral roots. Holthouse 2 mentions a woman, aged forty-two, who dropped from the height of a third-floor window on to her feet. Com- plete paralysis of the lower limbs and retention of urine and faeces followed immediately. On the third day (before which no examination appears to have been made) she was found to have no sensation or reflex in the soles of the feet ; micturition and defaecation were involuntary. On the sixth day is the some- what more complete record that she had no sensation in the soles, but that there was some feeling in the calves, " and in the whole of the [? other parts of the] limb on the right side, but not on the left." Three days later she was said to have anaesthesia below the ankles. There ensued a bed-sore on the sacrum, cystitis, and erysipelas, and the patient died on the nineteenth day. At the autopsy was found a crush of the first lumbar vertebra, 1 Anatomic Palhologique, torn, ii., Maladies de la Moelle, p. 5. 2 Lancet, 1858, vol. ii. p. 629. INJURIES OF THE LUMBO-SACKAL REGION. 137 fragments of the body of which had been driven backwards, " and had crushed that part of the spinal cord just above the cauda equina ; " there was no effusion of blood or inflammatory deposit. In these two last cases, which are so closely similar in their symptoms, we should expect to find anaesthesia of the " saddle- shaped " area, which is supplied by the third sacral root ; but it is exceedingly probable, especially when we consider the date of the observations and the sex of the patients, that such a condition would pass unnoted. As a conclusion to the above series of cases, I may mention the following example of tumour of the cauda equina, recently admitted to Mr. Jones's wards in the Manchester Infirmary for retention of urine, which illustrates admirably some of the above localisations, as well as the assistance to be obtained from the same in the diagnosis of the exact seat of spinal lesions. CASE 48. Tumour of the cauda equina, involving successively the various nerve-roots. J. D., aged thirty-one, was admitted to Mr. Jones's wards in the Manchester Infirmary on April 15, 1889. His family history is unimportant. He has had no previous illness, and presents no indications of syphilis or alcoholism. Some six years ago he began to suffer from pain in the lower part of his back, extending thence down the back of the lower limbs to the heels ; at the same time he had difficulty in micturition, which, after about three months, was followed by complete retention of urine for a week. The latter condition improved a little, and for about a year he was able to pass urine, but at the end of that time he again had absolute retention for about three weeks. Coincidently with these troubles he began to suffer from obstinate constipation. This condition of constipation, difficulty, and occasional failure in micturition, with pain in the back of the lower limbs, continued until about eight months ago. We may call this the first stage of his illness. Eight months before admission the pain in the back of the limbs disappeared, and was gradually replaced by " numbness ; " at the same time pain also began to be felt in the front of the thighs, from the hips to the knees, but no lower, and this pain has since continued. Along with this he has had marked feeble- 138 SURGERY OF THE SPINAL CORD. ness in the lower limbs, especially below the knees, and on the right side. From the eighth to the third month before admission he was unable to have connection with his wife, but had nocturnal emissions and erections. The bladder and rectal troubles con- tinued. This constitutes the second stage of the disease. Three months ago the pain in the front of the thighs, the numbness of the back of the limbs, and the muscular weakness became markedly worse, and he ceased to have any erections. Thus we reach a third stage. At the present time the lower limbs are a good deal wasted ; they present no paralysis, but all the muscles are weak, and the toes show a tendency to drop in walking; muscular sense is retained. The electric reactions are normal. The bowels are very constipated, and the urine is absolutely retained, the catheter being constantly required. Over the lower lumbar vertebrae, in the middle line, there is a region which is painful on pressure or movement. Pain affects the front of the thighs in a region corresponding to the dotted area in the diagram (fig. 31), but there does not appear to be any exaggeration of sensibility to pain or touch. Anaesthesia is no- where absolute, but there is very great blunting of sensation in the penis, scrotum (except at the upper part), perineum, gluteal region, and intero-posterior aspects of the upper parts of the thighs, this dulness of sensation extending, although in a less marked degree, down the centre of the backs of the thighs, over the calves, except on the inner side, and to the soles of the feet, where it spares the great-toe and half the second toe. Still slighter loss of sensation affects the front of the knees, the outer sides of the legs, and the outer side of the dorsum of the foot. In the leg and foot the sensory deficiency is more marked on the right side. The testicles are not anaesthetic. Some sensation is retained in the urethra, but it appears to be blunted. The annexed diagrams (figs. 31 and 32) represent these conditions roughly only, there being actually much less well-defined limits. The plantar and gluteal reflexes are lost on both sides, the cremasteric is retained, the abdominal appear to be exaggerated. Ankle-clonus cannot be elicited ; on the right side there is no knee-jerk ; on the left it was slightly marked on admission, but disappeared some ten days later. The general health remains good, except for some gastric dis- turbance. The eyes are normal in all respects. There can be no doubt that we have here a pressure lesion of the cauda equina ; the progress of events is too slow for us to sup- INJURIES OF THE LUMBO-SACRAL REGION. 139 pose that we have an affection of the spinal cord itself; the dura- tion of the case and the course of the symptoms, to which fuller reference will be made immediately, point to a tumour rather than to meningitis ; and the history and appearance of the patient contra- indicate tubercle, so that the growth is doubtless a tumour. Taking this view, we may thus explain the symptoms, remem- bering always that, in pressure-lesions of the cauda equina, the lower roots almost invariably suffer more than those which arise above them, and suffer first from an increasing pressure-lesion. In the first stage we have paralysis of the fourth sacral root, FIG. 31. FIG. 32. which supplies the bladder and rectum, together with irritation, causing pain in the sensory branches of the first three sacral roots. In the second stage, which came on eight months before admission, there ensued loss of power of coitus, due to paralysis of the muscles supplied by the third sacral root, and at the same time anaesthesia supervened in the previously painful areas, and the irritation was transferred to the third and fourth lumbar roots. In the third stage, which came on about five months later, the nervi erigentes are paralysed, thus indicating pressure on the second sacral roots, anaesthesia is well marked in the cutaneous distribution of all the sacral roots, and is less obvious in that of 140 SURGERY OF THE SPINAL CORD. the fifth lumbar, and pain is confined to the distribution of the third (? and fourth) lumbar roots. Motor weakness affects most of these roots, but is fairly marked in the second sacral, which supplies the extensors of the toes, &c., and is still greater in the third and fourth sacral, which are distributed to the bladder, rectum, and perineal muscles. The two first lumbar roots en- tirely escape. If now we inquire into the exact localisation of the tumour, we must place it below the upper border of the second lumbar vertebra, because here we have the termination of the spinal cord, which, from the nature and slow growth of the symptoms, is probably not affected (cf. p. 106). Again we must admit that the third lumbar roots are irritated by the growth, as there is pain in their cutaneous distribution. Hence then we conclude that it is situated between the upper border of the second and the lower border of the third lumbar vertebra. Lastly, the two following cases, although both are non-trau- matic, further illustrate the effects of a lesion implicating the third sacral and subjacent roots : A syphilitic woman, 1 aged thirty-two, suffered from absolute anaesthesia of the skin of the external genital organs, as high as the boundaries of the mons veneris, of the vaginal mucous mem- brane, the perineum, and the inner aspect of the thighs in the immediate neighbourhood of the perineum, and over the sacrum and gluteal region, as in Bernhardt's case. Together with this anaesthesia she had paralysis of the bladder and rectum, and a bed-sore over the sacrum, but no further paralysis or sensory affection of the limbs. A post-mortem examination revealed gummatous spinal meningitis in the sacral region, with " com- pression of the roots of the pudendal plexus" and superficial caries of the sacrum. A woman, 2 aged thirty-six, suffered, as the result of a severe cold, from pains in passing urine, with numbness of the nates, shortly followed by retention of urine and fseces, and, five days later, by involuntary micturition and defsecation. At the end of seven months she presented anaesthesia of the bladder, urethra, rectum, perineum, external genitals, vagina, uterus, and lower half of the nates, with continued involuntary micturition and defsecation, but with no affection of sensation or movement in the extremities. This condition was unchanged at the end of four years. 1 Westphal, Charite Annalen, Jahrgang I. Berlin, 1876. 2 Rosenthal, Wiener mcdizinische Pressc, 1888, No. 19. CHAPTER VI. THE INDICATIONS FOR OPERATIVE TREATMENT IN AFFECTIONS OF THE SPINAL CORD. OMITTING the suggestions of Paulas ^Egineta, Fabricius Hildanus, and others, and the case in which Louis successfully extracted the fragments of a vertebral arch broken by a gunshot wound, the earliest recorded instance of a definite operation having been undertaken, for the cure of traumatic compression of the spinal cord, appears to have been the case of Cline, who, at the insti- gation of Sir Astley Cooper, performed this operation in 1814. During the last three-quarters of a century some sixty similar operations have been practised, but the results have so far not been sufficiently favourable to recommend the procedure to the majority of surgeons. The enormous impetus given to operative surgery by the introduction of the antiseptic system and the recent achievements of cerebral surgery have, however, again naturally raised the question of the advisability of operating for the relief of injuries of the spinal cord ; and the brilliant successes of Mac- ewen and Horsley have extended the sphere of possibly beneficial interference from the traumatic to other compressing lesions of that structure. In the following chapter I propose to collect and to criticise such evidence as we possess, bearing upon a question which will probably before long be placed upon an entirely new basis. The subject may conveniently be divided into sections. SECTION I. TRAUMATIC LESIONS. Within the last few years five cases of spinal injury have been trephined in the Manchester Eoyal Infirmary, the details of which will be found recorded in the above pages. We may first con- sider briefly the circumstances connected with each of these. In Case 9 (p. 20) there was no question but that the cord was completely crushed, the condition of the patient was un- doubtedly hopeless, and an operation thus appeared advisable as allowing a possible chance of recovery, and as being certainly incapable of rendering matters more serious than they already were. As a matter of fact, not the slightest benefit resulted, and the post-mortem examination showed that the condition was not one 142 SURGERY OF THE SPINAL CORD. susceptible of relief, inasmuch as there was no pressure upon the cord, the bony displacement being very slight, and the damage inflicted upon the nervous structures having doubtless been en- tirely received at the moment of injury, when the cord had been completely crushed, and had been released only after destruction of its tissue by bruising and haemorrhage. In Case 8 (p. 17) the symptoms pointed to a lesion quite as serious as in the last instance, and here also the operation was a last resort in a desperate case. The result showed, however, that the spinal cord was here exposed to continued pressure from the displaced bones, and that this pressure must have been relieved by the removal of the counter-pressure due to the excised arches. In spite of this, not the slightest improvement resulted in the symptoms, and it seems not improbable that the operation may somewhat have shortened life, owing to further damage having been inflicted upon the compressed cord by the necessary manipu- lations, especially during the period of suspended respiration. In Case 1 1 (p. 2 6) the conditions were entirely different. The course of the case indicated clearly that the cord was not entirely destroyed, but that at least some of its conducting fibres main- tained their continuity. The spontaneous improvement, which for some time progressed very steadily, at first gave rise to hopes that extensive regeneration might result. Farther, the exaggeration of the plantar and patellar reflexes, and the fact that incontinence of urine, with an empty bladder, was present from the commence- ment, indicated at least that the reflex centres had not suffered from the usual shock, possibly that irritation rather than paralysis was playing an important part in the production of the symptoms. When, therefore, recovery had progressed for some time, and had then come to a standstill, it appeared probable that, by trephining, it might be possible to remove any source of irritation as well as of compression, and that the favourable course might thus be re- established. Without operation the patient's life was certainly not worth living, nor likely to be much prolonged, exhausted as he was by pain, sleeplessness, and cystitis. Further, the depres- sion of the fifth cervical spinous process, regarded in connection with the upper limit of the paralysis, appeared to indicate a dis- location forwards of the fifth cervical vertebra of the usual type, giving rise to narrowing of the medullary canal opposite the upper border of the body of the sixth. Even after the operation this view received countenance from the backward projection of the theca in this region. The result proved that there was no persistent compression of the cord ; that the lesion of the vertebral column was prac- INDICATIONS FOR OPERATIVE TREATMENT. 143 tically a diastasis only, and was at a higher level than had been anticipated ; that the affection of the cord was the result of a merely temporary crush, with extravasation of blood ; and that consequently an operation could by no possibility have been of any service. The cause of death was undoubtedly a re-establish- ment of traumatic myelitis, as a result of the local interference. Case 32 (p. 94) differed materially from the last three, both in the nature of the injury and in the result. The injury did not affect the spinal cord at all, but was confined to the cauda equina, and an interval of four months and a half had elapsed between its receipt and the date of the operation. During the earlier part of this period the symptoms had improved, but, as in the last case, this improvement had ceased, and for some eight weeks there had been no change in the patient's condition. The operation revealed a large amount of cicatricial tissue compressing the nerves of the cauda equina, and on the removal of this tissue improvement recommenced, and was eventually very satisfactory. In Case 45 (p. 131) the displacement of the spine was at the junction of the last dorsal and first lumbar vertebra, which would probably correspond to the region of exit from the cord of the fifth lumbar nerve-roots. 1 Hence the crush would affect the conus medullaris at this level, together with the nerves of the cauda equina, which here accompany it. The functions of the latter were only partially destroyed. After an interval of eighteen weeks, and after such slight improvement as was at first manifested had entirely ceased, the operation was resorted to. As in the last case, cicatricial tissue was found to be surrounding the nervous structures, and this tissue was removed ; besides which, the cord itself appeared to be almost entirely torn across. The subsequent improvement was practically nil, except for a slight recovery of function in the upper lumbar roots, which, having left the cord above the seat of the lesion, form the com- mencement of the cauda equina. The above five cases constitute the whole of my own experi- ence of the operation of trephining the spine, as performed for traumatic lesions, but I have collected in the Table which fol- lows all the recorded cases which I can find. Excellent sum- maries up to date are given by Gurlt, 2 Ashhurst, 3 and Werner, 4 and these have been freely used, being checked and supplemented by reference to such of the original reports as are accessible to me. 1 Gowers, Diseases of the Nervous System, vol. i. p. 106. Handbuch der Lelire von den Knochenbriicken. Hamburg, 1864. 3 Injuries of the Spine. Philadelphia, 1867. 4 Die Trepanation dcr Wirbdsaulc. Stras.sburg, 1879. 144 SURGERY OF THE SPINAL CORD. No Operator and Date. Reference. Symptoms before Operation. Period of Operation after Injury I Cline. South's Chelius, London, Total motor and sensory par- Second 1814. 1847. Vol. i. p. 539. alysis of the lower ex- j day. tremities. 2 "Wickham. Tyrrell's edit, of Total motor and sensory par- Eight days. 1819. Cooper's Lectures on i alysis of trunk and lower Surgery, London, limbs : partial of upper 1825. Vol. ii. p. 20. limbs. 3 Oldknow. Cooper's Fractures and V Six days. 1819. Dislocations, London , 1822. 4 Attenburrow. Tyrrell's edit, of > ? Cooper's Lectures on Surgery, London, 1825. Vol. ii. p. 20. 5 Tyrrell. Ibid., p. ii. Motor and sensory paralysis Two days. below Poupart's ligament : involuntary defsecation and micturition : depres- sion of twelfth dorsal ver- tebra. 6 Rhea Barton. Cooper's Fractures and Total paralysis of trunk and Twelve 1824. Dislocations, God- lower limbs : incontinence days. man's American ed., of urine and faeces. or Packard's Mai- f/aigne. 7 Tyrrell. Lancet, 1827. Total paralysis of lower One day. 1827. limbs : last dorsal dis- located backwards. 8 Alban Smith. North American Med. Paralysis, of all the limbs Two years. 1828. and Sury. Jour. Vol. except of muscles above viii. the elbow. 9 Holscher. Hannov. Anna!. /. d. Total paralysis of lower Thirteen 1828. oes. Hcilk. Bd. iv. limbs : obvious dislocation days. 1839. forwards : on I3th day commencing gangrene of sacrum. 10 South. South's Chelius. Lon- 9 \ don, 1847. Vol. i. P. 541. ii Rogeri. Amer. Jour. Med. Sc., Paralysis : great dyspnoea : Two days. 1834. O. S. Vol. xvi. depression of first lumbar spine. 12 Edwards. Brit. For. Med. Chir. Paralysis of lower limbs, "A con- 1838. Rev., 1838, and bladder, and rectum. siderable M'Donnell, Dub. time." Quart. Jour. Med. Sci., 1865. I3 Laugier. Lesions traumaliques Total motor and sensory Four days. 1840. de la Moet/e epinere. paralysis of lower limbs : Paris, 1848. retention of urine : bed- sore. 14 Potter. Hurd, New York Jour. Motor and sensory paralysis One hun- 1844 (?). Med., 1845. below the breast : violent dred days. pain in neck : bed-sores : cystitis. Previous lung disease. INDICATIONS FOR OPERATIVE TREATMENT. Nature of Opera- tion. Subsequent Course. Result. Region Affected and Post-mortem Appearances. Removal of two No effect. Death on nine- Fracture of twelfth dor- isolated spin- teenth day. sal, displacement of ous processes eleventh : cord al- and one of the most torn through. arches. Removal of part Freer breathing : distinct Death in one Fracture of seventh cer- of seventh cer- return of sensation. day. vical vertebra. vical vertebra. Rem oval of V Death on fol- Fracture of seventh cer- seventh cer- lowing day. vical : extensive ex- vical spinous travasation of blood. process. V v Death. 9 Removal of Immediate return of sensa- Death on fif- Fracture of last dorsal twelfth dor- tion on inner aspect of teenth day. and first lumbar verte- sal and first thigh : after one day sen- brae : exudation on lumbar arches. sation down to the toes : meninges: cord peritonitis secondary to healthy : cystitis : bladder mischief. peritonitis. Removal of Return of sensation after Death in 3^ Dislocation of seventh seventh dorsal second day. days. cervical, fracture of arch. ninth dorsal. Removal of Return of sensation in Death in eight Dislocation of twelfth twelfth dorsal hips. Death from pleu- days. dorsal vertebra. arch. risy. Removal of third Healing of a gluteal bed- Incomplete Middle dorsal spine : and fourth sore : return of sensa- recovery. vertebrae ankylosed. dorsal spines. tion as far as the thighs. Removal of "Wound healed in six Death in fifteen General oedema : hydro- eleventh and weeks. Return of sen- weeks. pericardium : connec- twelfth dorsal sation in lower limbs : tive tissue masses at arches. slight mobility of legs : site of operation. could sit up. Removal of an ? ? ? arch which was fractured on one side. Removal of Relief of breathing: return Death in ten Fracture of first lumbar twelfth dorsal of sensibility in lower days. vertebra : cord nor- and first lum- limbs : pain in feet. mal. bar arches. Gangrene of right foot, where there was a com- pound fracture. Elevation of one Lived for fifteen years : Incomplete re- Lumbar region. of the lumbar return of functions of covery. arches. bladder and rectum : afterwards father of children : could never walk. Removal of spine Slight relief of respira- Death in four Fracture of seventh, of eighth and tion in two hours : days. eighth, ninth, and arch of ninth pneumonia, &c. tenth dorsal vertebrae : dorsal verte- cord completely torn : brae. fractured ribs : pneu- monia. Removal of parts Almost immediate return Death in eight- Lower cervical and of four lower of sensation : wound did een days. upper dorsal regions. cervical and well : later, respiratory two upper dor- troubles. sal vertebrae. K 146 SURGERY OF THE SPINAL CORD. No. Operator and Date. Reference. Symptoms before Operation. Period of Operation after Injury. 15 Walker. Catalogue of the Mu- Motor and sensory paralysis One day. 1845. seum of the Boston below the breast: dysp- Society for Medical noea : retention of urine : Improvement, 1847. incontinence of faeces : priapism. 16 Mayer. v. Walther and v. Am- Immediately after blows About six 1846. mon's^owr. der Chir- from a stick, pain and dis- months. urgie. Bd. 38. tinct cracking in back : two months later, increas- ing weakness in back and anaesthesia of lower limbs. In five months total motor and sensory paralysis of \ trunk and lower limbs : incontinence of urine : difficult respiration : pain- ful crepitus on movement. J 7 Blair. Ballingall's Outlines of ? 9 1852. Military Surgery, Edinburgh, 1852. 18 Blackmail. American edit, of Vel- Complete motor and sensory Four and 1854- peau. Vol. ii. p. 392. paralysis of lower limbs : a half incontinence of urine and years (?). faeces : irregularity of upper part of sacrum. J 9 Blackman. Hutchison, Amer. Med. 9 Five hours. 1854. Times, 1861. 20 Jones, G. M. Med. Times and Ga- Motor and sensory paralysis Six days. 1856. zette, 1856. Vol. ii. below sternum : arms p. 86. could only be moved upwards : sensation in arms, but not in fingers : excessive priapism : dia- phragmatic respiration : retention of urine : cere- bral symptoms. 21 Hutchison. Amer. Med. Times, Total motor and sensory par- Ten days. 1857- 1861. alysis below umbilicus : no reflexes : priapism : re- tention followed by incon- tinence of urine : respira- tory troubles : depression of eighth and ninth dor- 22 Smith, Stephen. 1858. Hutchison, Ame>\ Med. Times, 1861. sal spines with crepitus. Motor and sensory paralysis below sixth intercostal One day. nerve : numbness and for- mication in arms : reten- tion of urine : priapism : bed-sores on second day. 23 Potter, H. A. 1859- Amer. Jour. Med. Sc. N. S. Vol. xiv. Total paralysis, except that the hands could be slightly A few days. raised. 24 Potter, H. A. Ibid. Same case as last. Con- Three years. 1862. tinued paralysis : general condition good. INDICATIONS FOR OPERATIVE TREATMENT. 147 Nature of Opera- tion. Subsequent Course. Result. Region Affected and Post-mortem Appearances. Removalofsixth Return of sensation in Incomplete re- Sixth cervical. cervical spin- three days, complete in covery. ous process, two and a half months : which was later control over blad- broken but der and rectum : mus- not depressed. cular tremors, contrac- tures : slight atrophy : slight power in lower limbs. Resection of Return of voluntary mic- Death in Compression and de- seventh dorsal turition. For nine days twenty-one generation of cord arch, which restoration of sensation days. opposite seventh dor- was obviously in lower limbs with sal : impacted fracture compr e s s i n g hyperaesthesia and tre- of this vertebra with- the cord. mors, but no motor out callus : fracture power : then exhaus- of several spinous pro- tion, fever, and bed- cesses : abscess in an- sores. terior mediastinum. ? ' ' A successful result." ? ? Removal of if After some hours, con- Incomplete re- Sacrum. ins. of upper sciousness of micturi- covery. part of sacrum, tion, and a day later of which was de- defsecation : gradual re- pressed. turn of sensation, and, after five weeks, of voluntary power in legs. ? Death in eight Fracture of upper dor- days. sal spine. Resection of Return of sensation as far Death on fifth Fracture of bodies of third and as umbilicus, and freer day. fifth and sixth cervi- fourth dorsal movement of arms on cal vertebrae : extra- arches : no in- same day : return of vasation in and around jury found : bladder sensation : sud- cord : tearing of then resection den death. nerve-roots. of fifth and sixth cervical arches. Removal of No improvement : respir- Death on Fracture of several dor- eighth and atory failure : wound twentieth day. sal spinous processes, ninth dorsal gangrenous. three bodies and two spines and ribs : cord torn : pyo- tenth dorsal pneumothorax. arch: cord laid bare for 2\ ins. Resection of de- No improvement. Death soon Fracture of tenth pressed arch after the dorsal : no disloca- of tenth dorsal operation. tion : extravasation of vertebra. blood from cervical vertebras to sacrum. Resection of fifth Wound healed in three Incomplete Fracture of sixth cer- and sixth cer- months : could sit and recovery. vical spinous pro- vical arches : move head : left hand cess : dislocation : cord pulsated. freer mobility : spastic arch of fifth almost symptoms in lower divided cord. limbs. Resection of No effect. Unrelieved. Cord not united : theca fourth, sixth thinned. (?), and se- venth cervical arches. 148 SURGERY OF THE SPINAL CORD. No. [Operator and Date. Reference. Symptoms before Operation. Period of Operation after Injury. 25 Potter, H. A. Amer. Jour. Med. Sc. ? j i86o(?). N. S. Vol. xiv. 26 M'Donnell. Dublin Jour. Med. Sc. Paralysis of lower limbs, Thirty- 1865. Vol. xl. bladder, and rectum : seven days. anaesthesia of soles of feet : loss of reflexes : bed- sores : prominence of first and depression of second lumbar spine. 27 Gordon. Dub. Journ. Med. Sci. Paralysis of lower limbs, Sixty-eight 1865. Vol. xlii. bladder, and rectum : days. bed-sores. At end of eight weeks total paralysis of lower limbs except thigh, which was paretic only : sartorius not affected : anaesthesia in feet : above this numbness : hyper- sesthesia of right thigh : no reflexes below knee. 28 Willett. Lancet, 1866. Vol. i. Complete motor and sensory Two days. 1865. paralysis of all limbs and trunk : threatened as- phyxia on second day. 29 Tillaux. Bull. fltn. de TMrap. Total motor and sensory Nine days. 1865. mid. et chir., 1866, paralysis of lower limbs : p. 202. no reflexes : retention of urine and faeces : semi- erection : difficulty of breathing : bed-sores : de- pression of first lumbar spinous process. 3 Tvrrell. Dub. Journ. Med. Sci. ? Two days. ' 1866. Vol. xlii. 3 1 Maunder. Lancet, 1867. Vol. i. Motor and sensory paralysis Twenty- 1866. (not quite complete) be- two days. low nipples : diaphragma- tic respiration : retention of urine and faeces fol- lowed by incontinence : prominence of seventh cer- vical spine. 32 Clieever. First Med. and Snrfl. Paralysis of motion and sen- Three 1867. Rep. of the Boston sation in lower limbs : liours. City Hospital, 15os- priapism : dyspnoea : ton, 1870, p. 577. coma : crepitus at fifth and sixth dorsal vertebrae : emphysema : probably fractured ribs. INDICATIONS FOR OPERATIVE TREATMENT. 149 Nature of Opera- tion. Subsequent Course. Result. Region Affected and Post-mortem Appearances. Resection of fifth, i Death in four Cord not torn : large ex- sixth, and se- days. travasation about for- venth cervical amen magnum : frac- arches : dis- ture of occipital and tinct pulsation left parietal bones. of cord. Resection of last On first day return of sen- Death on seven- Fracture of first lumbar dorsal (?) arch: sation in soles, and of teenth day. vertebra : dislocation dura unopened. power in thighs : fourth forwards of twelfth day, sensation normal : dorsal : cord compres- seventh day, return of sed but not inflamed : reflexes : improvement cystitis, pyelo-ne- in bed-sores and urine : phritis, &c. some power over blad- der : marked power in thighs, none below knees : then rigors, diar- rhoea, sudden death. Resection of first Urine acid after fourth Incomplete re- Fracture of twelfth dor- lumbar or day : on twenty -sixth covery. sal or first lumbar. twelfth dorsal day normal micturition : arch : dura in eight weeks return of not opened. sensation and partially of motion in lower limbs: bed-sores healed: in six months could sit up easily; still had in- voluntary defecation : exfoliation of a splinter of bone. Not completed. Death during Dislocation of fifth cer- operation. vical : extravasation of blood. Removal of first Rigors, delirium, &c. : Death in eleven Transverse fracture of lumbar spiu- f paralysis extended to hours. first lumbar without ous process, clavicles. displacement : dura which was uninjured : cord not broken off torn, but contained and displaced: effusion of blood and dura not com- showed ascending pressed. myelitis : haemor- rhage in vertebral canal, but no com- pression : fracture of eighth and ninth ribs. > Wound doing well for first ? Injury of lower part of three weeks. vertebral column. Resection of first Relief of dyspnoea and Death on I3th Seventh cervical par- and second cough, and of pain : day. tially dislocated for- dorsal arches. death from respiratory wards : cord softened : troubles. pyaemia. Removal of com- "Respiration modified by Death in Upper dorsal. minuted spin- operation. " twenty-four ous processes hours. of second, third, fourth, and fifth dor- sal vertebrae, and third and fourth laminae. SURGERY OF THE SPINAL CORD. No. Operator and Date. Reference. Symptoms before Operation. Period of Operation after Injury 33 Cheever. First Med. and Surg. Complete paralysis below Twenty- 18 . Rep. of the Boston nipples : partial in upper four hours. City Hospital, Bos- limbs : abdominal respira- ton, 1870, p. 577. tion : depression opposite sixth cervical vertebra : retention of urine : tym- panites : high fever. 34 Willard. Amer. Jour. Med. Sc. Motor and sensory paralysis A few 1871. Vol. Ixiii., April of lower limbs : retention hours (?). 1872. (Chicago Med. of urine. Jxaminer,Oct. 1871.) 35 9 St. Bartholomew's Hos- A man aged 30. 9 pital Rep. Vol. vi. 36 Nunneley. Med. Times and Ga- 9 9 18 . zette, August 1869. 37 Nunneley. Ibid. 9 9 18 . 3 Nunneley. Ibid. ? Ten days. 18 . 39 Nunneley. Ibid. 9 Five weeks. 18-. 40 Stemen. Fort Wayne Journ. 9 9 18 . Med. Sci. 1883 (Lidell, Ashhurst's System of Surgery). 4i Stemen. Ibid. 9 18 . 42 Stemen. Ibid. 9 9 18 . 43 Maydl. Albert, Lehrbuck der 9 9 188-. Chirurgie, Vienna, 1884. Vol. ii. p. 55. 44 Liicke. Werner, Die Trepana- Complete motor and sensory Thirty-six 1877. tion der Wirbelsdule, paralysis of twelfth dorsal hours. Strassburg, 1879. and subjacent nerves : re- tention of urine and faeces : tympanites : cremasteric reflex present, plantar slightly marked : de- pression of eleventh dorsal spine : crepitus. 45 Macewen. Brit. Med. Jour., 1888. "Absolute motor paralysis Six weeks 1885. Vol. ii. p. 308, Case [of lower limbs], with in- (?) vi. continence : " hypersesthe- sia : wasting of limbs : loss of electric reactions : bed-sores : cystitis : fever. INDICATIONS FOE, OPERATIVE TREATMENT. '5* Nature of Opera- tion. Subsequent Course. Result. Region Affected and Post-mortem Appearances. Removal of No improvement : hyper- Death in nine Forwards dislocation of sixth and part pyrexia (110). hours. sixth cervical. of fifth cer- vical arches. Removal of Apparently no change. Death on tenth Second lumbar. second lumbar day. arch, which was fractured. 9 Death. ra 9 Death. " Injuries such as not to allow of recovery tak- ing place." ? Death. Do. ? Death. Do. [Nunneley's cases are all very briefly referred to by himself.] 9 Excellent health for z\ Partial re- 9 years after, but leg re- covery. mained partially para- lysed. ? Relieved. 9 9 Not benefited. 9 9 9 Death. 9 Resection of two ' ' The patient recovered 9 Dislocation in dorsal vertebral from the operation. " region : cord was arches in dor- crushed. sal region. Removal of com- Several times during oper- Not benefited. Probably dislocation minuted frag- ments of bone ation slight pressure on cord caused movements and fracture of eleventh dorsal : cord pressing on the of lower limbs (in spite compressed. cord, and' re- of deep chloroform nar- [Slight improvement at section of en- cosis) : partial recovery first, from relief of tire arch and of sensation in three- pressure : then appa- left trans verse quarters of an hour, im- rently myelitis.] process (of proved by extension : eleventh dor- hence extension by sal) : cord weight of about six was somewhat pounds to each leg : flattened : ex- movements of toes on tension gave eighth day : pleurisy : more space : cystitis : bed-sores : ex- wound su- foliation of a small se- tured except questrum : finally in centre : woundhealed: complete "Listerian anaesthesia and para- dressing. " lysis: bed-sores: incon- Removal of frac- tured twelfth tinence of urine, &c. Same night limbs warmer: third day, toes mov- Partial re- covery. Fracture of twelfth dor- sal vertebra. dorsal arch, able : after a month and dense con- tenotomy for contrac- nective tissue tures : then rapid gain on posterior aspect of dura. of power : in three years could ' ' move about with ease, but with a para- plegic gait." SURGERY OF THE SPINAL CORD. No. Operator and Date. Reference. Symptoms before Operation. Period of Operation after Injury. 46 Lauenstein. Centralblatt fur Chir- Could not stand, but moved Ten weeks. 1886. urgie, 1886. No. 51, legs in bed : limbs wasted p. 888. and cold : reflexes slight : no anaesthesia : unconsci- ous defsecation : retention and overflow of urine : cystitis : failure of plaster jacket : subsequent fever and general marasmus, with some anaesthesia of right thigh : angular cur- vature. 47 Keetley. Brit. Med. Jour., 1888. Motor and sensory paralysis Three 1888. Vol. ii. p. 421. below fifth cervical nerve : hours. priapism : depression at back of neck. 48 Horsley. 1887. Med. Chir. Trans. Vol. Ixxi., 1888, p. Absolute motor and sensory paralysis of lower limbs : A few days 400. loss of control over blad- der and rectum : cystitis : severe bed-sore : promi- nence of eleventh dorsal spine. 49 Horsley. Ibid. "A fracture." r 5 Duncan. Edin. Med. Jour. , Complete loss of motion and A few 1888. March 1889, p. 830. sensation from the groin hours (?). downwards : retention of urine : projection and mo- bility of eleventh dorsal spine. Si Duncan. Ibid., p. 831. ' ' Complete paraplegia : " re- One day. 1889. tention of urine : projec- tion of third lumbar ver- tebra : extreme collapse. INDICATIONS FOR OPERATIVE TREATMENT. 153 Nature of Opera- tion. Subsequent Course. Result. Region Affected and Post-mortem Appearances. Removal of Cord touched during Completely Dislocation of twelfth twelfth dorsal operation, causing con- cured in six dorsal vertebra. and first lum- traction in limb : to this months. bar arches is attributed temporary the former total paralysis in pe- comminuted rouei : shortly severe and of thicken- pain in back and limbs : ed dura : care- wound healed on fourth ful antiseptic day : fifth day, pain and precautions. fever ceased, improve- ment in urine and an- aesthesia : in three months could stand erect and urinate. Removal of fifth Slight improvement in Death in Vertical fracture of and fourth cer- sensation on second day: seventy hours. fourth cervical : ver- vical arches : hypersesthesia : respira- tebral canal patent : membranes ex- tory troubles : wound cord completely di- posed, free almost healed. vided opposite fifth from tension, cervical vertebra. unusually soft. Removal of Slight improvement in Partial Fracture of eleventh eleventh dor- sensation : none in par- recovery. dorsal : haemato- sal spine, alysis : bed-sore healed : myelia. which was de- cystitis recovered: pressed, and of wound healed in seven tenth dorsal days. arch : dura healthy : not opened, but accidentally punctured. ? Wound healed " without > ? any complication what- ever." Removal of tenth, Wound healed on ninth Unrelieved. Fracture of tenth, eleventh, and day : no change in eleventh, and twelfth twelfth dorsal symptoms. dorsal arches : dis- arches : dura placement forwards not opened. of body of tenth, not more than \ in. Removal of On following day wound Death on se- Fracture of third and arches of se- doing well : sensation cond day. dislocation forwards cond and third had returned to con- of second lumbar ver- lumbar : body siderably below the tebra : displacement of former dis- knees : breathing sud- perfectly reduced : placed about denly became embar- cauda very slightly i in. forwards : rassed : cyanosis : fail- bruised : rupture of membranes ure of respiration. diaphragm, hernia of blue and dis- stomach, and great tended : dura omentum into left opened, giving pleural cavity, &c. exit to blood Death due to other and clots: injuries. cauda not much affected: wound in dura closed: dis- placement of bones reduced, and reduction maintained by pads and plas- ter jacket. 154 SURGERY OF THE SPINAL CORD. No. Operator and Date. Reference. Symptoms before Operation. Period of Operation after Injury. 52 Duncan. 1889. Edin. Med. Jour., March 1889, p. 832. Absolute paraplegia as high as groin : retention fol- Thirty-six days. lowed by incontinence of urine and fasces : much collapsed : great extrava- sation of blood in back : projection of second lum- bar spine. 53 Pe"an. Hart, Brit. Med. Horse-bite on back, appa- 1889. Journ., 1889. Vol. rently only a slight i. p. 672. "pinch of the skin:" after some days nervous symptoms came on gradu- ally : great pain in back : complete paralysis of lower limbs : retention of urine : prominence of sixth and depression of seventh and 54 Allingham, H. Brit. Med. Journ., eighth dorsal spines. " Paralysed from below the 9 1888. 1889. Vol. i. p. 838. level of the ensiform car- tilage ;" "seemed to lose ground." 55 Allingham, H. Ibid. " Paralysed from a level Six days. 1888. seven inches above the umbilicus. " 56 Dawbarn. 1889. New York Med. Jour. , June 29th, 1889, p. Complete paraplegia, begin- ning a few inches below Six months. 711. the ribs : involuntary de- faecation : retention and overflow of urine : cystitis : anaesthesia as high as um- bilicus, except over toes, where was slight sensation : projection of twelfth dor- sal spine, depression and deflection to left of ele- venth : no improvement during one month. INDICATIONS FOR OPERATIVE TREATMENT. 155 Nature of Opera- tion. Subsequent Course . Result. Region Affected and Post-mortem Appearances. Removal of No improvement up to Unknown. Dislocation of first lum- arches of first seventeenth day : free bar vertebra: fracture three lumbar flow of cerebro-spinal of second. vertebrae : fluid, which began to parts much diminish in a week, but matted t o- was still continuing on gether : first seventeenth day. lumbar dis- placed for- wards about an inch : cord torn half through and bent twice at a right angle : sheath above and below in- jured region sewn together, relaxing latter portion: some cerebro- spinal fluid escaped. Exposure of the "Patient is now restored Recovery. Middle dorsal. arches, which to almost his ordinary were commi- condition." nuted : ten fragments re- moved from the spinal cord. Removal of fifth, Healing of wound in ten Partial (slight) Depression and fracture sixth, and days : some improve- improvement. of sixth dorsal lami- seventh dorsal ment, " the level of the nae. laminae expos- paralysis being brought ing cord: anti- down to the umbilicus." septic treat- ment. Removal of Wound healed in about a Death in seven Cord almost divided : third, fourth, fortnight : bed-sores : months. "both ends tapering fifth,and sixth cystitis, &c. down to a fine point." dorsal lami- nas: dura opened. Removal of "\Voundsoonhealed: after Slight Junction of eleventh tenth, ele- ten weeks, pain had improvement. and twelfth dorsal venth, and ceased : more power over vertebrae. twelfth dorsal bladder and rectum : arches : dura some return of power not opened : in sartorii : readier re- cord bent at sponse of muscles of angle of 15 : limbs to electricity : anti - septic limbs became warmer dressing. in a few hours. 156 SURGERY OF THE SPINAL CORD. Such being the available clinical evidence, we are now in a position to coDsider the question, how far is the future practice of this operation advisable ? In the first place, we may clear the ground somewhat by stating, as beyond dispute, that in cases of compound fractures of the arches (chiefly gunshot wounds), foreign bodies and bony fragments should be removed, and the wound treated antiseptically. No possible harm can accrue from so obvious a procedure, which was apparently first practised by Louis. In the above Table cases of this nature have not been included, and they need not now be further referred to. Taking all other cases together, we may arrive at a decision after answering the following series of questions: (i.) How far are spinal injuries curable without operation? (2.) Is the opera- tion itself necessarily fatal, or so dangerous as to be unjustifiable ? (3.) If successful, is it likely to leave the vertebral column in a condition too weak to perform its functions ? (4.) Does the operation hold out a prospect of improvement in all or any cases ? and if the latter, in what cases ? Let us take these points seriatim. I. Are the results of fractures and dislocations of the spine incurable without operation ? Practically, we may say that the vast majority are. Gurlt records 217 deaths out of a total of 270 fractures; but even when there is "recovery," there are usually persistent nervous symptoms which render life little but a burden, and which would warrant extreme measures for their relief. There are also among these recoveries fractures of the vertebrae, in which, owing to the cord not having been involved, no nervous symptoms are produced ; but for these no one would suggest trephining, and they cannot influence the decision in cases of injury to the cord. A few cases remain, and they are very few, in which a fairly satisfactory recovery is made, and in which we should not be inclined, for the relief of such slight symptoms as remain, to subject the patient to a major operation. It will, however, be found that in all such cases recovery sets in early, pro- bably within a few days of the accident, and that such recovery is progressive, so that when the process has once been checked, we find no further change for the better, however long the patient survive. These are obviously cases in which there is no permanent source of compression of the cord, but in which probably a diastasis or partial luxation of the vertebrae has pro- duced a contusion of the cord or of its nerve-roots. We may conclude, then, that in a small percentage of cases, in which the symptoms indicate only a partial transverse lesion of the nervous structures, recovery may begin shortly and progress INDICATIONS FOR OPERATIVE TREATMENT. 157 steadily. In these cases we do not require, and therefore should not practise, an operation. In all others in cases in which the transverse lesion is complete, in which, although it be partial only, there are no signs of improvement within a week or two, or in which improvement, after having gone on steadily for a time, comes to a standstill recovery will not ensue. For these cases trephining might be practised in the absence of any other means of relief. II. Is the operation necessarily fatal, or so dangerous as to be unjustifiable ? Necessarily fatal it obviously is not, and under modern conditions it does not appear to be a very dangerous procedure. Of the above total of sixty-one cases, including five original and fifty-six quoted, only thirty-five are recorded as deaths, or about fifty-seven per cent., a proportion comparing favourably with the eighty per cent, of deaths in Gurlt's analysis of fractures not operated upon, and which is only raised to sixty- seven per cent., even if we regard the six cases in which the result is unknown as having all ended fatally. Such figures, however, regarded apart from contingent circumstances, hardly give us a fair estimate of the danger incurred by operating. The majority of the fatal cases were evidently doomed apart from the operation, and in but few could the latter be regarded as the cause of death. More to the point is the fact that physiolo- gists have very frequently trephined the spines of animals, and that in such cases untoward results are unusual. As throwing some further light on the question, I have made an analysis of twenty undoubted cases of wounds, by sharp instruments, to the cord or its membranes, in human beings, and among these we find only five deaths. If we reflect that these wounds were made, not by the surgeon, but by accident, and that many were not treated antiseptically, we must conclude that the only special danger of the operation, septic meningitis or myelitis, has been much exaggerated. Hence it would appear that the dangers of the operation are comparatively not great, especially in view of the conditions which it is designed to relieve. III. It has been argued that even a successful operation would leave the vertebral column so weakened as to be unable to per- form its functions as a support to the body or a protection to the spinal cord. This contention is at once disposed of by the records of cases which have survived. In no single instance has such a difficulty been encountered. There is, moreover, no reason why the spinal envelope should not be strengthened by the re-implantation of such vertebral arches as have been 158 SURGERY OF THE SPINAL CORD. elevated, a procedure which has been successfully adopted by Mr. Wright in a case of spinal caries (infra). IV. Does the operation hold out any prospect of recovery in all or any cases ? and if the latter, in what cases ? Even when we have established the incurability of crushes of the cord apart from trephining and the practicability of that operation itself, it will be necessary before adopting it to give an affirmative reply to this question ; and here it is that the main difficulty arises. Post-mortem evidence shows that three conditions may be met with as the early results of a crush of the spinal cord, due to fracture or dislocation of the body of a vertebra. In many cases I should be inclined to say in the majority of cases there is not found any serious narrowing of the vertebral canal after death. The displaced bones commonly fall back immediately after the injury into their original position, leaving the contused cord free from pressure. In other cases the displacement of the bones is maintained, and the cord is compressed, usually between the body of the lower and the arch of the upper of the affected vertebrae. In a small minority of cases pressure upon the cord is due solely to the effusion of blood. In the first group of cases operation is clearly useless ; the whole mischief is already done and the cord is in as favourable a position for repair as can be supplied to it. In the second and third groups only, can we by operation remove the source of pressure, and for the present we may neglect the few cases constituting the third group. We have, therefore, to ask ourselves what benefit is to be derived from relieving the cord from the pressure of a permanently displaced vertebra. There is here aprima facie probability that nothing will be gained. It can hardly be doubted that, when the bones are continuing to press upon the cord, the mischief done to it will be at least as severe as, probably more severe than, it is in those cases in which they are not. But as these latter rarely recover, in spite of the comparatively favourable conditions, it is highly improbable that the former will do better after trephining. In other words, clinical evidence points to the fact that the damage done by an acute compression of the cord is usually irreparable that the cord is incapable of repairing an extensive crush. Cases of haDmatomyelia point to the same conclusion : life may be spared, but rarely, if ever, are no permanent symptoms produced, simply because the structures immediately destroyed by the haemorrhage undergo no regeneration; and therefore, if, as in severe crushes, there be a practically complete transverse haemorrhage, there will result a permanent complete transverse lesion. In face of these facts it INDICATIONS FOR OPERATIVE TREATMENT. 159 is useless to point to experiments upon animals in which the structure and functions of the cord are said to have been more or less restored after section ; the more so as the results of such experiments are still open to doubt. In human beings, as in animals, clean sections are capable of repair. Among the twenty cases of wounds by sharp instruments to which I have already referred, there are eighteen in which the cord appears to have been more or less divided. In four of these complete reco- very ensued, at intervals of two months and upwards ; and in six there was partial recovery ; in one the record ceases on the tenth day, when improvement was clearly in progress. But there is a wide difference between a clean cut and the effects of a crush ; and, as has been indicated, the latter appears to be hopeless. The fact remains that a certain amount of improvement may follow a crushing lesion, due probably to the recovery of those portions of the cord structure that have only been compressed and not de- stroyed by the haemorrhage ; but it appears highly improbable that any such tissue will remain to a cord permanently flattened by displacement of the body of a vertebra. Trephining has been strongly urged by Dr. Brown-Se'quard and others, on the ground that the more serious symptoms of a crush are not paralytic, but irritative, and that operation will re- move the source of irritation. Into this somewhat doubtful ques- tion I do not propose now to enter, further than to say that clinical experience does not seem to confirm this view. The trophic troubles which result from those injuries in which exaggeration of reflexes and other symptoms would indicate irritation are not more severe than those found in cases in which every other symptom points to a pure paralysis, and paralytic lesions may undoubtedly give rise to the vascular changes which accompany, even if they do not cause, such trophic troubles. But even where we have evi- dence of irritation, we have no proof that it is due to the pressure of displaced bone. Thus in Case 1 1 (p. 26) there were marked evidences of such irritation, and yet the post-mortem showed that there was no bony pressure upon the cord, and that the mischief arose entirely from haemorrhage and subsequent inflammation. As above stated, I have seen but one other case in which there was early increase in the knee-jerk, probably indicating irritation of the reflex centres, and there other symptoms showed con- clusively that the injury done to the cord was comparatively slight, and recovery ensued without operation. Hence, even if we grant the lesion to be irritative, we cannot expect to remove the source of irritation of the cord by trephining the spine ; both 160 SURGERY OF THE SPINAL CORD. the irritation and the paralytic effects are equally the result of a lesion of the nervous structures, which, once produced, is inde- pendent of the position of the vertebrae. On these grounds, then, it would appear that no benefit can result from operating for most traumatic injuries to the spinal cord, and that operation is therefore unjustifiable in such cases. We must, however, draw an important distinction between the spinal cord and its nerve-roots. The structure of the latter is very different from that of the cord itself, and they must be con- sidered merely as peripheral nerves. As such, they are, in the first place, far more resistant to compression. An injury which would convert the cord into a mere mass of blood-stained pulp might damage a nerve-trunk very slightly. That nerve-trunks may and do recover after severe injuries is a fact capable of daily observa- tion. Even complete division and separation of the ends of a nerve is no barrier to its recovery, unless some other tissue intervene between its separated portions or unless the latter be very far apart. And even in the latter case the removal of the obstacle may be, and generally is, followed by reunion at dates frequently very remote from that of the injury. This being the case with regard to peripheral nerves elsewhere, we must expect the same results to follow in the case of injury to the intraspinal roots. Where the latter run in contact with the cord itself, the above considerations will have no practical bearing, as the cord lesion far transcends in importance that of its associated roots. But below the lower border of the first lumbar vertebra we have a region, frequently injured, in which the spinal roots have still a long intraspinal course, but in which the cord has no place. Here then we have a new condition a region in which a spinal injury implicates peripheral nerves only, and in which we may on & priori grounds hope to do much by relieving these nerves from pressure. We may also assume that, in injuries of the cauda equina, if the symptoms be permanent, they are due to some removable source of pressure, as to displaced bone or cicatricial tissue. Were the injury a contusion melrely, these roots would doubtless spontaneously recover their functions, as do other peripheral nerves so injured. These theoretical considerations are confirmed by the statistics of recorded cases. Thus of the sixty-one cases collected, sixteen appear to have "partially" or wholly recovered, there being two complete recoveries only, viz., Cases 53 and 46. Omitting for the moment Case 53, which will be subsequently referred to, we thus find fifteen more or less satisfactory results. Of these INDICATIONS FOR OPERATIVE TREATMENT. l6l fifteen, one is our fourth case (p. 94), in which the lesion clearly involved only the cauda equina. The others are Cases 8, 12, 15, 17, 18, 23, 27, 39, 40, 45, 46, 48, 54, and 56 of the Table. Of these, the region of injury is unknown in Cases 17, 39, and 40, thus leaving for consideration eleven cases only from which we can derive any information of value, and of the latte again, Case 8 is a record of somewhat doubtful validity. Cases 15, 23, and 5 4 are injuries above the lumbar region, but in Case I 5 the operation was performed the day after the accident, and there is not the slightest indication that the patient would not have progressed equally well without it, and in Cases 23 and 54 the evidence of real improvement is slight. The only in- stances, therefore, in which the locality of the injury is known, and in which there would appear to have been a bona fide im- provement, are Cases 12, 18, 27, 45, 46, 48, and 56, in which the injury affected respectively one of the lumbar vertebrae, the sacrum, the twelfth dorsal or first lumbar, the twelfth dorsal, the junction of the twelfth dorsal and first lumbar, the eleventh dorsal, and the junction of the two last dorsal vertebrae. Of these seven, the two first almost certainly affected the cauda only ; in the third the termination of the cord was probably injured, and clearly the terminal region (supplying the bladder and rectum) did not, as regards the latter at any rate, share in the recovery ; to the fourth (45) the same remark applies; in the sixth (48) the partial recovery is probably due entirely to the nerve-roots, and not to the cord ; in the seventh (56) the improvement was almost trivial ; and in one only (46) is there anything like satisfactory evidence of recovery of any portion of the spinal cord itself. It would appear, then, that we may sum up as follows : That the operation of trephining the spine for traumatic lesions, as compared with the condition which it is intended to relieve, does not present any very great dangers, and appears unlikely to increase the gravity of the prognosis, but that as both h priori argument and the results of published cases show that it is unlikely to be of service, it should be abandoned, except in cases of injury to the cauda equina, and that in the latter, on the other hand, it will probably prove to be an eminently justifiable and serviceable procedure. But even in injuries of the cauda equina we are not called upon to operate in every case. Many of these will progress most favour- ably or recover completely without any interference ; and if there seems to be a fair prospect of such recovery, our treatment should be expectant. Both from the evidence of the cases given above L 1 62 SURGERY OP THE SPINAL CORD. and from that supplied by the results of injuries to nerve-trunks elsewhere, it would appear that the chances of recovery are not seriously diminished by postponing operation for a reasonable time. Before we interfere, we should therefore be assured that nature will not effect a cure. Experience, however, shows that if spontaneous recovery is about to take place, it will not be very long in commencing, and will follow a fairly continuous course. Under these circumstances, I should be inclined to lay down the rough rule, that if at the end of six weeks there is no recovery, or if recovery is at a standstill, then, and then only, should we operate for crushes of the cauda equina. Another and very different class of exceptions to the doctrine of non-intervention in injuries to the spinal cord is furnished by those cases in which the injury has affected not the bodies, but the arches of the vertebrae. In the latter the pathological con- ditions differ entirely from those found in the former. The crush of the cord is obviously not liable to be so severe where the laminae only are depressed, as it is when the entire vertebra is displaced and the cord is subjected to the weight of a consider- able portion of the body. In pure fractures of the laminae, also, the consideration that the bones have probably at once regained their normal position, and that the cord has thus been placed in the most favourable position for recovery, has less weight, for these structures are frequently tightly wedged after injury, and are not subject to the natural extending forces of elasticity, of muscular action, and of the body weight. Thus the cord, having once been jammed, the pressure is more liable to be maintained. Again, a tightly wedged lamina will be subject to movement with every movement of the body, and will then be continually engaged in further ploughing up the cord. We may therefore hope to improve the patient's chances of recovery by the removal of a depressed arch, and the above considerations regarding the risks of the operation must lead us to the conclusion that such a pro- ceeding is here justifiable. In such cases, also, we should act with- out delay, as we cannot, as in the case of the cauda equina and the peripheral nerves, trust to the long retention of any capacity for regeneration which may be present in the structures involved, and as there is the constant danger of the infliction of further damage upon movement. A successful result in a case of this nature was obtained by Pe"an. A man received a bite from a horse in the mid-dorsal region, which was at first supposed to be only a "pinch of the skin." After some days nervous symptoms began to come on INDICATIONS FOR OPERATIVE TREATMENT. 163 gradually, and culminated in complete paraplegia, retention of urine, and severe local pain. After an interval, of which the duration is not recorded, Pean found, in addition to the above symptoms, a depression of the seventh and eighth dorsal spinous processes. Cutting down upon these, he removed about ten fragments which had entered the spinal cord, and, without any complication, the patient was " restored to almost his ordinary condition." The course of events in this case is not very clear, as, had the fragments been at once driven into the cord, which seems to be assumed in the report, the nervous symptoms would have been immediately produced. Probably, therefore, the broken arches were secondarily depressed by movement or pressure ; but however this may have been, the case illustrates the advantages which may result from the excision of bony spiculas actually in contact with or penetrating the spinal cord, when the latter is not crushed beyond repair. SECTION II. CARIES OF THE VERTEBRA. Ashhurst l states incidentally that portions of the vertebras were removed "for disease" by Heine, Roux, Holscher, and Dupuytren, but I have been unable to find the records of these cases, and the first operation of this nature with which I am ac- quainted is that performed by Jackson in 1882, since which time several similar cases have been subjected to the same procedure. All of these have been collected in the following table : 1 Loc. cit., p. 56. 164 SURGERY OF THE SPINAL CORD. i a sr-^ >> 5^ B S ^ " 0) a"- I 3 > o O o s 3J fV! p ^ A ; Symptoms after Operation. gSa-ggag .S-c.S'c S.S3.2-8 111111^ lt,i|;!i ^Ifll! 1 ! l-lig*i2 i1 s S^|s s-s3.il s- 5 j J.||il1.s| iRlillll SlMlll^a 1^121^11 fplfl&s&P iS football, &c. In ten hours limbs warmer, less livid, and with sub- jective sensations : on fourth day continence of urine and faeces : sensa- tion returned quickly, motion slowly : in eight months could walk a quar- ter mile : in four years remained well. Nature of Operation. ^If-gg^S "IBIS'S -sJlJ^j* !..**!? H* '43" o^^S^i, 2> 1 51^11 sal-? Is-lss*^ 8 'S -S 1 1, - -2 3 s g- os -^Sggs "i n a wo M v *g .S I ^^SBP Symptoms before 1 r at,>a>-^os a>S <-! c us S IsJI 1 ^"-!!!!^*! _. iHilitlvlliil! ilflPlllPllrMi ^-i2 a Mj3o M c2B-s2'- ;: 25 tt :t S -S s '3 > 3 '^ ^ .S 45 3 S .2, S 4 M ea TC c 8 ^ "^ 00 M *rr 5> . CO O > $ s a S CO :~ iS 1 '*" S "*s . ", 0) V H M ^; ^-J .rcj 2:=^?- O = " S oo "^ ^ ^ x ^ O ^i <^ (^ 1 S % I d ^ -A c ? e g CcB . K 1 O D N fe - CO 1 4 % O CO 2 "o^L" 2 2. "2 o co _ S. 4 S S s 6 H M CO * INDICATIONS. FOR OPERATIVE TREATMENT. 165 K ci C T3 I* s T3 > b -t> O 0> V ~= "rt 0) 11 o-a ^ -fi d i o> 1 E o 6 a Q ^ 1^ M p P3 s Q -= V 2 c'o'o i B "S >,B-8 JS fe rt s o e >A S gH^S 2 "g Deration possibly hasten death, sath from tuberculosi wound healed. iprovement in respirati temporary only : broncl pneumonia. ound healed without co plication : movement legs on eighth day : arms later : rapidly : gaining power, ound healed in a few daj on twelfth day returni sensation, which spre down limbs : on twenl seventh day could feel p: pricks as low as left fc and right knee : on 1 teenth day, flexion thighs possible : on fifl first day began to get wor and was in a few days bad as before operatic after six months in sta quo. (See also 13.) i third day could nio ankles and recognise touch : on seventh d could move knee : on foi teenth could move It throughout and local sensation : at end of months could walk a lit: with spastic gait, and cor feel well : wound heal on seventh day. O Q B i i O r3 C f-> j-r > ^3 O d.i _ 05 > i , u) . S 00 <-t Cw -u O 1 -fi 8 S S ."S aT ? 5 o p ^"5,2 jj i -8 5-w 3 g. o "S cj cS ^ rt o "** "3 "1 a 18| *"" 3 fl cj 'S ~'c ^^ o S r*^ flr 3 y " 5 r^ M "*J 3 rO "tO "i rQ ^ 6 +3 C S " 5 '43 .= 60 G g S 00 Q? r^ U C n , (_, 0} 5 G ^ ^" J *^ c3 " 5 fl B M *pi 2 cJ 03 W ^ o ^ ^ S ArM CJ ^ t ?? 'C rffrS s |1 2 1 l>,a ^ is -2 rf M * I'i's .. *< l|| ||| 1 ^ 2"" s> >-S "rg ijfj 111 11- "e fill ||c| t-i ^ -o p^ B 8 8 rt H fcl ' Olr-} C ' ' 1 K ' ..mi.. <*-! tt L * 4B QJ^ i 4g K m SS2fc '3.2J.JJ V '5 on S 'S ^g e8'43 ? o _c s O 3 2 > * .2< go-* 02 .- J .2 T **f* 8 -*J c> *^ M ^ 3 o 3 .. fi N o> b S ^^ m _ "2" 5 o 5 A 05 "5 r-y <*J "" S f ~ "* TJ 2 ^- c* S^" rB ^o to"S cj QJ J - m > * 8 ^" CC.^H & 0> . . p p i> ^ ^ .1^ CD"^ ^ -*i S d p: ~ s- ""^ ^ r^ ^ G CH CO*'* 3 x te 03 03 r^J *^ S *"* S *S ^ S S 4i ci o x "^ "IT T3 ^ ^ Si c3 'Tfi *~ _T ^ c5 ft ^ -*-3 HQ O r , ^*3 r P 5 < a O 3 i Mir* si *~ a yi'V c f .. s I..IP !-ll 'S t) *S * 3 fi 6 81 2 s -2 |;5 ol SJa g C-&J 5^ s u 1 5 ^ a) o x X b 0) CJ p * K e o-c o3 ^< o n ! a's-lsi |$ 1 2 2 3 Qj^2 S o* W cS-SaoeStDcS'Oei -e:3 of(i oo' .r K _ 00 d ^ *5 e oo 00 O oo ^~ <^ oo H ^ p^ ci oo . si > . M *J" ^ "^ p ' " . * "^ ^ o ^ CO s ,^ ** oo 2 2 "1 00 ' X fl fe 'w O O - W r*o *3r$ i-s J o 5 \o "S 2 -j ~j SL? "fe = O ^st ,9 s> 3 s &* -O -o >! e H Cq .- T? ^i. -2 . i f 'e' s C g s-i . J ^3 c i* > 5 *o s oo i *" od 9 " OO C i "Sgoo 'S .Sfa C 'S 00 S.M 0^- M S ^ s CO K P Q tr 1 * tN CO o M 1 66 SURGERY OP THE SPINAL CORD. f Oi *G 1 a "3 rH v ~ a * a _o |.plf|| J1ljjili|;sli '-3 To ^ &" | gjg * "g ^ k'o'^S d. r S r p4 "* s osi^.B ff-'S^a 'C 03 fn S ^ *n O c5 c} fen 03 O "" H r") * O i- C* -*l *"* -2 ^'c'H " ^ 1 1 -S ^"^ 2 =* I S**^ o g " K C-r'^- L 3, . aSr:^ "3 c? cS bX)"^ -2 "^ QJ "*"* ^^? l ^^'Sc 3 ^3 5 ^S ,O^S 3.2 II1II5 SQ p; ^ i j'n^ 01 g 6 M 'H M" * .g ^ g -a ' 2ta g O -3 | .."fi - a" 3 c'S " "- 13 c o> ^ s s o 1 ^"go'^o'u r 2 c3 2o'^ 3 " < (D P 1 0, O lriii SpiiJI i* W C ^3 ^i O _g *o rtMM^ojSGs ^a>2 cS '- (llJ '^ 2 "S^g ) a> ^^S"^> .. 3 1 Hill ill "i 2 "2* 0*73 a c s o os >H r-l M a < s||fi^'ss^' < s |s^6|.g| J5 1 *-S | M J E J * 2 ^ 7o ^ J ^ I ii! "iirr.il - f-Jl^ Ov 2 a S C!C _Q 60 ^^ r 2SS cs 'c M 'i r S'JoS2a i"^ "i" ^ &S 6 a c'JIj s||^ cJJ g i o-SSj'c D CQ 1 ' S i O t . j 3 3 O "* 15 a | 2 ^ - ^ QQ* . <) = 8,2 ^^ P. 2 te; 1 O d 5 b 88 g tf O. ^ M Q " f O 6 H n ro K w w H la 55 PQ <4 EH INDICATIONS FOR OPERATIVE TREATMENT. 1 67 The results of these thirteen operations are as follows. In two only (5 and 12) does the operation appear to have done harm; in three (6, 7, and 13) no relief was afforded; in one (9) marked improvement resulted, but a relapse occurred, prc- bably from recurrence of the inflammatory compression ; and in the remaining seven we have most obvious relief. The clinical history of the latter group demonstrates clearly that this relief was a direct result of the operation, and was not due to a chance connection. From these figures then we deduce at once the conclusion that in certain of these cases surgical interference is of undoubted value, and it remains only to ask what are the indi- cations for the operation. It is generally recognised that the nervous phenomena result- ing from spinal caries are not due to the mere curvature of the spine ; that the latter leaves the vertebral canal little, if at all, diminished in size ; and that the implication of the cord arises from some other cause. It is equally certain that the lesion is not in most, if in any, cases an acute myelitis, but rather a result of pressure, to which the changes in the cord structure itself are secondary. This pressure may be exercised by solid fungating masses springing from the bodies of the vertebrae, or by acute inflammatory swelling or haemorrhage in connection with the meninges, but by far most frequently it is the result of a chronic thickening of the latter. Hence, then, although other causes may be at work, much the most common is chronic localised pachymeningitis compressing the implicated section of the cord. This conclusion is adopted by most writers upon the subject, 1 and is in accordance with the writer's own experience of a considerable number of post-mortem examinations. It follows, therefore, that we may best hope to relieve these nervous phenomena in those cases in which they are of compara- tively slow onset, although it may be possible, as was attempted in Case 7, to extend the operation to more acute cases of com- pression by suppuration or by haemorrhage. The chances of success in such an operation must be regarded as very doubtful, but we cannot yet say that it may not have its uses. Up to the present time, however, benefit has ensued only in cases of chronic pachymeningitis, a limitation of the scope of the opera- tion implied also in Mr. Mace wen's rejection of cases in which there is rise of temperature. Having thus a clear idea of the condition which we hope to relieve, two other considerations only are necessary. Of these, the most obvious is that we must 1 Elliott, New York Med. Jour., June 2, 1888. 168 SURGERY OF THE SRIKAL CORD. freely remove the thickened perimeningeal connective tissue, and that only when this has been done can we hope for any good result. The other is that paralysis secondary to spinal caries has, even when of long duration, a remarkable tendency to recovery, if the recumbent position be rigorously maintained, and that we must therefore not operate too early, but must first be convinced that no improvement will result without such inter- vention, the more so as the frequent occurrence of late recovery itself indicates that we are not seriously diminishing our chances of success by such delay. SECTION III. OTHER PRESSURE LESIONS. It having once been proved, as it has been, that the operation of trephining the spine falls within the range of practical surgery, and that chronic pressure lesions of the cord are, even after long duration, susceptible of very great, if not, in some instances, per- fect recovery, it follows that the operation is practicable and advisable in any such disease in which the source of pressure is accessible for removal, and is not amenable to other methods of treatment. In the case of tumours of the membranes or nerve-roots, this has been demonstrated in the most practical manner possible by Mr. Horsley's brilliant operation, and obviously that which can be done for intravertebral tumours can be equally well done in the case of tumours of the vertebrae themselves, and tumours growing into the spinal canal from other regions, provided that the anatomical connections of these growths are not such as to preclude removal. An interesting case of this nature has recently been operated upon in the Manchester Infirmary by Mr. Wright, who is reserving a full report until after the lapse of a longer period, but who has kindly permitted me to use the following notes : CASE 49. Fibro-sarcoma of neck involving brachial plexus and invading spinal canal Removal Cure of spinal symptoms. A. H. , aged thirty-eight, was admitted on August 6, 1888, under the care successively of Drs. Morgan and Eoss. For some twenty years he had noticed a slowly-growing swelling on the left side of his neck. Fifteen months before admission he first observed numbness and weakness, of progressive character, in INDICATIONS FOR OPERATIVE TREATMENT. 169 the left arm ; three months later the left leg began to fail, and recently the right arm and leg had been losing power. There was a history of alcoholism, but not of syphilis or any hereditary disease. On admission, the tumour was about the size of an orange, seated in the posterior triangle of the neck, well defined in outline, slightly mobile, firm and elastic ; pressure upon it caused pain in the distribution of the ulnar nerve : no other growths were discovered. The left arm was weak and the muscles wasted, the flexors of the wrist and fingers and intrinsic muscles of the hand being mainly affected ; " claw-hand " was well marked; partial anesthesia affected the ulnar side of the forearm and hand. The right arm was also weak, but without atrophy or impairment of sensation : here also the paresis was rather more marked in the flexors of the wrist and fingers, and in the intrinsic muscles of the hand. The deep reflexes at the wrist and elbow were increased. The left lower limb presented the usual evi- dences of spastic paralysis : the right was but slightly weakened. The left eye projected a little. Pupils normal. General health good. Anti-syphilitic and other treatment proved of no avail, and all the above symptoms became gradually intensified. The spastic symptoms extended to the right lower extremity, the muscles of both lower limbs becoming tonically rigid ; paralysis increased, and, on the left side, extended to the upper arm muscles. On August 2 ist, 1888, the tumour in the neck was removed by an ordinary dissection ; it was about the size and shape of a lemon, and distinctly encapsuled, and was afterwards found to consist chiefly of fibrous tissue, with portions which were clearly sarcomatous, and with areas of myxomatous degeneration. A projection penetrated one of the intervertebral foramina, appa- rently that for the third cervical nerve, and the base of this pro- cess having been ligatured, the chief mass of the growth was torn away, the appendage being temporarily left in situ. A second smaller growth, about the size of an egg, was now found lying below the first, and this, which resembled the latter in character, was also removed. Both growths were connected with the cords of the brachial plexus. Attention was next turned to the projection which invaded the vertebral canal. The implicated foramen was large enough to admit the tip of the little finger, and a Volkmann's spoon being thus introduced into the canal, the growth was carefully and gently scraped away. There was no haemorrhage or other trouble, and the spray, with other anti- septic precautions, was used throughout the operation. The wound was healed on the twentieth day. Nervous symptoms I7O SURGERY OF THE SPINAL CORD. were almost immediately relieved. On the day after the opera- tion the contractions of the lower limb muscles were much slighter, and thereafter they ceased entirely. At the same time the lower limbs began to regain power. The right arm also increased markedly in power, and the grasp, which had been almost entirely lost, became quite strong again. The left arm improved to a less extent, but the forearm muscles regained some power, whereas those of the upper arm did not. The improvement thus noted occupied about three weeks, after which the patient was dis- charged. Some time later, when last seen by Mr. Wright, he could walk, and the right upper limb was almost well, the left in statu quo. There can be little doubt that the growth had here penetrated the vertebral canal along the course of the left third cervical nerve-root, that the latter had been comparatively little injured at first, but that on entering the canal, the growth had more seriously implicated the less resistant tissue of the cord itself, and had grown across the anterior aspect of the latter. In this way only can we explain the comparatively trivial sensory troubles, the spastic symptoms in the upper and lower limbs, and various other minor points. The chief damage was no doubt done to the cords of the left brachial plexus. The operation greatly relieved the pressure upon the cord, but the damage done to the roots of the plexus outside the spinal canal appears to have been irreparable. Although the case is not one of "trephining the spine," in the ordinary sense of the term, it falls within the category of intravertebral operations, and illustrates the benefits to be derived therefrom. It remains only to add that similar procedures may clearly be adopted for cysts, for otherwise incurable pachymeningitis, for chronic rheumatic arthritis of the vertebrae with compression of the cord, and possibly for certain meningeal hsemorrhages, either at an early stage, when life is directly threatened, or later, should absorption be unsatisfactory. 1 1 As, the above is passing through the press there has appeared a report by Drs. Dercuin and White (Annals of Surgery, June 1889) of two cases in which the latter opened the spinal canal. In the first the diagnosis is obscure, but severe nervous symptoms recovered shortly after the operation, in which the dura mater was opened. The second was a case of tubercular pneumonia, caries of the vertebrae, and acute myelitis : death ensued within thirty hours of the operation. Dr. Abbe (Xew York Med. Jiec., February 1889) has also opened the spinal canal and divided several of the cervical nerve-roots close to the dura mater, in a case of intractable neuralgia : the patient survived and manifested some improvement in his symptoms. CHAPTER VII. OPHTHALMOSCOPIC CHANGES IN INJURIES OF THE SPINAL CORD AND IN TRAUMATIC NEUROSES. FEW subjects have been less investigated, and on few is the information which we possess more conflicting, than on that of the changes seen in the fundus oculi after injuries to the spinal cord, the original observations upon the point being remarkably limited in number, while the references found in medical literature are mainly more or less accurate expositions of the work of but very few observers. Under these circumstances, I have thought it worth while to make a few fresh investigations, and to compare the results with the conclusions arrived at by others. A double source of confusion has been introduced into the con- sideration of this subject a confusion of which we must in the first instance endeavour to divest ourselves. It is exceedingly common to find after severe shocks to the nervous system cer- tain eye-symptoms retinal irritability, photophobia, retinal weak- ness, muscae volitantes and other subjective phenomena, dis- turbances of accommodation (especially if there be previous refractive error), weakness of the internal recti, and last, but not least, more or less complete loss of vision, with marked restriction of the visual field. These conditions are recognised as retinal, accommodative, or muscular asthenopia and as " hyste- rical " amblyopia, of the last of which affections several instances will be mentioned in considering traumatic hysteria. They are all purely functional troubles, and bear no relation to any organic changes in the fundus oculi, nor, so far as I can find, is there a single instance on record in which such symp- toms were followed by optic atrophy, although many writers certainly convey the impression that in nearly all such cases ophthalmoscopic changes eventually supervene. 1 Hence, then, 1 Cf. Erichsen, Science and Art of Surgery, 8th edit., London, 1884, vol. i. p. 777. 172 SURGERY OF THE SPINAL CORD. at the outset, superfluous as it may seem, we must insist upon the truism, that the existence of changes in the optic nerve or disc cannot be established unless objective evidence of such change be forthcoming, as the result of either an ophthalmoscopic or a post-mortem examination, and that the presence of subjective visual troubles is not necessarily any indication of organic disease. The second source of confusion to which I have referred is that until recently it has been customary to describe as " concussion of the spine " a large number of cases which are now recognised as neurasthenic or hysterical, which may collectively be denomi- nated traumatic neuroses or traumatic neuro-psychoses, and which are in no way dependent upon lesions of the spinal cord. Here again, then, we must reiterate a second truism, that those cases only should be regarded as injuries of the spinal cord in which there is definite evidence of some lesion of that structure. In order to obviate as far as possible these two initial difficul- ties, which appear to have insensibly crept into and complicated the descriptions of many writers, we must therefore confine our attention strictly to cases in which changes in the fundus are proved, and not merely inferred to exist ; and we must carefully distinguish between bona fide injuries of the spinal cord on the one hand, and the large class of traumatic neuroses on the other. To keep clear this latter important distinction, it will be well to discuss separately the visible optical changes : first, in definite organic lesions of the spinal cord ; second, in slighter injuries to the back, not directly implicating the spinal cord, and unaccom- panied by such circumstances as cause severe shock to the nervous system ; and third, in injuries of which the local con- ditions are similar to the last, but which are complicated by more or less severe general shock i.e., practically, railway injuries. I. INJURIES OF THE SPINAL CORD. In the above pages there will be found thirty-eight personal observations of severe injuries to the spinal cord, the records of which cases, including fractures, dislocations, and ha3mor- rhages, constitute the basis from which my own conclu- sions have been drawn. Of these thirty-eight cases, seventeen were injuries below the level of the third dorsal nerve-roots. In none of the seventeen were there ever any subjective eye- symptoms, 1 and, in nine at least, I failed, on examining the discs, 1 There was one doubtful case, in which, however, repeated investigations failed to Bhow any changes in the fundus (p. 123). OPHTHALMOSCOPIC CHANGES. 173 to find anything abnormal. Hence, although the evidence is purely negative, my own experience would appear to indicate that, in severe injuries below this level, ophthalmoscopic changes do not arise, even at long intervals after the receipt of the injury. The majority of the injuries have been considerably below the third dorsal nerve, but the considerations which follow lead us to assign to the upper dorsal region the dividing-line between cases which do, and those which do not, give rise to changes in the disc. There is, however, one recorded case which apparently points in an opposite direction. Mr. Bruce Clarke l reports the case of a man who, having been struck b}^ a falling weight, sustained a frac- ture of the fourth, fifth, and sixth dorsal vertebrae, with complete division of the cord at the level of the fifth and sixth, dying on the tenth day. On the third day it is stated that " there is well- marked hyperaemia, with considerable oedema of both discs ; a good deal of effusion obscures the vessels in many places." But here it was noted on the second day that breathing was " entirely diaphragmatic," and on the third that there was well-marked hyperaesthesia of the chest ; so that it appears highly probable that myelitis had rapidly extended for a considerable distance above the injured region,, and had reached, at least, to the extreme upper limit of the dorsal portion, before any optical changes were found ; from which it would follow that the excep- tion is apparent rather than real, and that the eye-troubles may be traced to an extension of the cord mischief above the level of the dorsal region. Very different results are obtained from a study of cases of injury above the second dorsal nerve, i.e., above the level of the " cilio-spinal centre." The twenty-one cases of injury in the cer- vical region above described include fifteen of fracture or disloca- tion, with one recovery, and six of intraspinal haemorrhage, four of which recovered, and in one of which (Case 2 I ) the patient lived for eighteen months after the accident. In no case, either of recovery or of early or tardy death, did any subjective eye-symptoms present themselves, and we may therefore assume that in none were there any very serious papillary changes. In seven cases, however, we have definite ophthalmoscopic obser- vations, of which the results are as follows : I . (Case 8.) A man, aged thirty-three, was struck upon the back of the neck by a weight, receiving a fracture of the fifth and sixth cervical vertebrae, with dislocation forwards of the fifth, and suffering from total paralysis, anaesthesia, &c., below the level of 1 St. Earth. Hosp. Rep., vol. xvi., 1880, p. 171, Case 4. 174 SURGERY OF THE SPINAL CORD. the lesion. He died on the seventh day, the diagnosis being con- firmed by post-mortem examination. I examined the discs on the sixth day, finding no abnormality. The pupils and palpebral fissures were small, and the former did not dilate upon irritating the skin of the back of the neck. 2. (Case i 3.) A woman died in forty hours from fracture-dislo- cation between the sixth and seventh cervical vertebrae, with the usual symptoms of a crush of the spinal cord, the consequent paralysis extending rapidly to the phrenic roots. The lesion was confirmed by post-mortem examination. I examined the eyes within twelve hours of the accident, finding the right disc nor- mal ; the left could not be seen owing to an incipient cataract. The only mobile pupil was reduced in size. 3. (Case 14.) A man died in thirty-one days from a dislocation of the last cervical vertebras. There were the usual symptoms of a crush of the spinal cord, and the post-mortem examination established the diagnosis. On the seventeenth day I found both discs normal and identical. The pupils and palpebral fissures were contracted on both sides, but especially on the right, where there were other evidences that the cervical sympathetic was more severely injured. 4. (Case 15.) In a case of unilateral dislocation of the fifth cervical vertebra, with incomplete crushing of the cord, causing paralysis, anaesthesia, &c., below the injured region, the disloca- tion was reduced, and the man gradually recovered almost com- pletely. I examined his discs on several occasions, within the first few weeks after the accident, without finding any changes. The pupils and palpebral fissures were, as usual, diminished in size. In these four cases, then, there was no evidence of changes in the disc, but, as we shall shortly see, the examination in Case 1 3 (and perhaps also in Case 8) was too early, and that in Case 14 too late, for us to affirm that no such change had or might have arisen. Case 15, in which the cord injury was not very com- plete, is the only one in which we may safely assume that the optic discs were unaffected. There remain three other cases. 5. (Case 10.) A man, aged thirty-three, sustained a fracture of the sixth cervical vertebra, with dislocation forwards of the fifth. He died on the twenty-ninth day, and the post-mortem examination confirmed the diagnosis. The symptoms and appear- ances were those of a crush of the cord in the region named, with myelitis ascending for some little distance, but with no evidence of basic meningitis. The palpebral fissures and pupils were small, and the latter did not dilate on pinching the skin of the neck. OPHTHALMOSCOPIC CHANGES. 1/5 On the third day the optic discs were perfectly normal. On the fifth day their margins were less well defined than before, and there was slight congestion of the retinal veins. On the sixth day the discs were still more hazy, but there was no obscuring of the vessels by effusion. Thereafter they were not examined. 6. (Case 12.) A young man sustained a fracture of the first dorsal vertebra, with dislocation forwards of the seventh cervical. He died on the tenth day, and presented the symptoms and post- mortem appearances of a crush of the cord at the region referred to, with some ascending myelitis, but with no evidence of basic meningitis. The palpebral fissures and pupils were contracted, and the latter did not dilate on pinching the skin of the back of the neck. On the third day the optic discs were a little hazy and ill-defined, there being also slight venous congestion of the retina. On the fifth day the same symptoms were present, but there was no evidence of effusion. On the ninth day the discs were more indistinct than before, and the smaller vessels were quite obscured by exudation. 7. (Case 11.) After an injury to the spine this patient pre- sented the symptoms of a crush of the cord above the level of the sixth cervical root, followed by myelitis, which slowly extended upwards for some ten days and then ceased. Improvement now commenced, and for another fortnight there was gradual return of power in some of the muscles of the upper limbs, after which the condition was unchanged. On the fifty-sixth day the laminaa of the affected vertebras were removed ; the myelitis at once began to reascend, and eight days later the patient died. He had no symptoms of basic meningitis. The autopsy confirmed the diag- nosis. Both pupils and palpebral fissures were contracted through- out. On the second and third days after the accident, he had profuse lachrymal secretion, with congestion of the conjunctive and flushing of the face. On the morning of the third day the left hand was warmer and redder than the right, and in the even- ing the condition was reversed ; but on the fourth day the left was again redder and somewhat congested. On the sixteenth day I examined the discs for the first time, and found them both hazy, with ill-defined outlines and doubtful engorgement of the retinal veins. Two days later I could find no abnormality in the right disc, but the left was still hazy as before, the difference between the two being very obvious. On the following day Dr. Little kindly examined the eyes, and found the right disc perfectly healthy, whereas " the left was hazy, with some distension of the vessels and haziness along their course." Dr. Little had no doubt 176 SURGERY OF THE SPINAL CORD. that there was at this time a pathological change on the left side, especially in view of the difference between the two eyes. On the thirty-third day I again found both discs slightly hazy, the right being less well defined than at the last examination, but the left less obscured, so that their condition was now practically the same. On the thirty-ninth day both discs were quite clear and healthy. On the forty-fourth day Dr. Little again reported, " Both optic nerves quite healthy and alike, well defined, and no haziness whatever." Hereafter I made no examination until the day before death, when I was unable to detect any departure from the normal, but when, owing to the patient's condition and restlessness, it was difficult to make a satisfactory examination. From the above facts it will appear that in four cases of crush of the upper portion of the spinal cord (third cervical to second dorsal), where frequent examinations were made, ophthalmoscopic changes were found in three, being absent in one only ; that in three other cases such changes were absent on the first, sixth, and seventeenth days respectively ; and that in six cases which survived the accident for long periods no subjective symptoms arose, so that optic atrophy probably never ensued. In the three cases known to be affected the changes consisted in haziness, with want of definition of the disc, accompanied by slight distension of the retinal veins. In the first case, the changes ensued on the fourth or fifth day after the accident ; they in- creased until the sixth day, but were not investigated at a later period. In the second case, they had commenced on the third day, increased on the fifth, and been followed by effusion, ob- scuring the smaller vessels, before the ninth, after which death prevented further change. In the third case, the haziness and congestion were found on the sixteenth day, but may have been present previously ; the right eye almost immediately afterwards returned to the normal condition, the left getting worse ; then the left improved, and the right again presented congestive changes ; and finally, on the thirty-ninth day, both were normal. In all the cases there was evidence of paralysis of the cervical sympathetic ; in the last, remarkable vascular and secretory changes occurred both in the face and upper limbs, and consecu- tive myelitis first got worse, and then again improved. In none was there any evidence of basic cerebral meningitis. So far as I can ascertain, the occurrence of similar changes in the optic disc in cases of spinal injury has not hitherto been described, but on the other hand there are no complete observa- tions which would indicate a negative view. True, Dr. Clifford OPHTHALMOSCOPIC CHANGES. 177 Allbutt l states that in seventeen "severe injuries, which proved fatal within a few weeks," no changes appeared in the eye, and that such " changes do not become established in the cases which run a short course, but they slowly supervene in the course of weeks or months in more chronic cases." We are, however, not told how often or at what intervals these fatal cases were examined, and enough has been said to show that, without fre- quent observations, the changes might readily be overlooked. On the other hand, the description given by Dr. Allbutt of certain effects which he observed in " chronic " cases of spinal injury coincides almost exactly with the appearances above referred to ; and in similar accord with his statement, that (always in chronic cases) these changes are the more readily produced the higher is the lesion, is my observation of three (acute) cases in the cervical region and of none at a lower level. These coincidences are the more remarkable because, as will shortly appear, Dr. Allbutt has found these appearances only in chronic cases, whereas I have failed to detect them except in severe or " acute " spinal injuries. II. SLIGHT SPINAL INJURIES UNACCOMPANIED BY DIRECT LESION OF THE CORD OR BY FUNCTIONAL NEUROSES. Slight blows, bruises, and sprains of the back are exceedingly common. They may present only local symptoms (pain, &c.), or they may be accompanied by a sort of " pseudo-paralysis," in which, owing to the fear of pain, the patient avoids free move- ments of the limbs or spine, holds the back and other joints rigid, and perhaps does not even defaecate or urinate with his normal force. Cases of the latter description are fully discussed in the third chapter of Mr. Page's work on " Injuries of the Spine," * and it is unnecessary to explain more fully the kind of injury to which reference is now made. But in spite of the large number of such minor injuries to the back that come under observation annually in hospital practice, I have found none in which there were subjective eye-symptoms, nor have a considerable number of ophthalmoscopic observations revealed a single instance of any affection of the optic discs. Moreover, I find only one reported case of the kind in which such changes were said to have ensued, viz., that of Dr. Thorowgood. 3 The patient was a girl twelve years 1 The Ophthalmoscope in Diseases of the Nervous System, &c., London, 1871, also Lancet, January 15, 1870. 2 Second edit., London, 1885, p. 120. 3 Transactions of the Clinical Society of London, vol. viii., 1875, P- &> M 178 SURGERY OP THE SPINAL CORD. of age, who received a blow apparently not a severe one on the lower part of the back. The pain which was thereby caused soon disappeared, but shortly afterwards she had pains at the back of the neck, with tenderness, slight swelling, and muscular stiffness ; this also got better in a few days. Then, a month after the accident, she rapidly lost the sight of both eyes and was found to have the condition of " choked discs." The latter again reco- vered in about a month, leaving the girl in perfect health. These changes are attributed to " slowly progressing basic meningitis " involving the optic nerves ; but I fail to appreciate the grounds for such a diagnosis, especially as the ophthalmoscopic appearances are quite different from those found by any other observer after spinal injury, and I can only regard as a pure accident the super- vention of uncomplicated acute optic neuritis a month after a blow on the lower part of the back. In certain cases, however, slight injuries of the spine may be followed by a subacute or chronic spinal meningitis, but such cases are unquestionably uncommon, only two having come under my own observation among some four hundred railway accidents and spinal injuries due to various causes. Again, chronic dege- neration of the cord is said occasionally to follow the slighter spinal injuries, but this also must be a rare condition, and it is one which I have not personally met with. If, however, there be produced, as the result of an injury, either chronic meningitis or chronic degeneration of the spinal cord, may we meet with ophthalmoscopic changes ? Dr. Clifford All- butt states that he found such changes in eight out of thirteen cases which he examined ; but unfortunately he does not describe the cases, and it is perhaps permissible to doubt whether they were all genuine spinal injuries. His paper appeared in 1870, at which time " traumatic hysteria" was hardly known and trau- matic neurasthenia hardly recognised, all obscure effects of injury to the nervous system being called injuries of the spine. Verriest l also records a case, which appears to have been an instance of chronic traumatic myelitis, and in which optic neuritis resulted. But, with these exceptions, we have no reported cases of secondary traumatic spinal disease giving rise to optic neuritis, the obser- vations of Mr. Wharton Jones being, as we shall shortly see, described too vaguely to constitute reliable data. Hence, then, we may perhaps sum up this section of the sub- ject thus : Slight spinal injuries are very common, but there is no evidence that they tend to be followed by changes in the 1 Page, Brain, 1 886, vol. ix. p. 262. OPHTHALMOSCOPIC CHANGES. 179 optic disc. Such injuries are, however, in rare cases followed by chronic meningitis or myelitis, and in the latter condition there is an a priori probability that optic neuritis may supervene. Both of these affections are, however, very rare, and with the exception of Dr. Allbutt's eight cases, in which we have not the materials for an accurate diagnosis, there is but one recorded instance of this conjunction. III. TRAUMATIC NEUROSES, WITH OR WITHOUT SLIGHT INJURY TO THE SPINE. Under the above heading are included those cases, best illustrated by the results of railway collisions, in which, although there may have been some slight sprain of the spine, the result- ing symptoms are due mainly to a traumatic neurosis. The cases differ from those of the last section in the presence of this latter most important factor, and the distinction between the two groups is of the greater consequence, as it is not impossible that it is to the neurosis, rather than to the spinal injury, that we owe such changes in the fundus as are sometimes met with. Here also, however, changes of the optic disc are so rare, that, among the numerous railway injuries which have come under my own observa- tion, and which include many severe cases of traumatic neurosis, I have seen but one doubtful case of lesion of the optic disc a case which will be more fully referred to below. The functional eye-symptoms, to which reference was made at the beginning of this chapter, are more often present than absent, but in no instance have I seen them followed or accompanied by organic changes. For obvious reasons, I do not always make an ophthal- moscopic examination in such cases, unless there is some sugges- tion of eye-mischief ; but we may safely assume that had many of those which were not thus examined presented any pathological change, the attention of the railway company concerned would probably have been attracted to the matter in at least one instance. My experience is therefore directly opposed to the teaching of most writers, who appear to regard optic neuritis as a frequent result of " concussion of the spine ;" but the discrepancy is sus ceptible of explanation. In 1869 Mr. Wharton Jones 1 first stated that he found ophthalmoscopic changes in certain traumatic cases, but he gave no details, and no account of the cases in which the changes were found, nor of the frequency with which 1 Failure of Sight from Railway and other Injuries. London, 1869. I So SUKGERY OF THE SPINAL CORD. lie had observed them. One year later Dr. Clifford Allbutt 1 published the observations already referred to. In 1875 appeared the second edition of Mr. Erichsen's work on " Concussion of the Spine." Having enumerated the various subjective symptoms already referred to, he gives an excellent account of their path- ology, and then passes on to quote largely from Mr. Jones and Dr. Allbutt. After a long extract from the latter, he says : " One or other of these conditions occur in the majority of cases of spinal injury, such as we are describing in this work," leaving on the mind of the reader the impression that the " one or other of these conditions " refers to the different ophthalmoscopic changes observed by Dr. Allbutt. This extraordinary verbal confusion has since been repeated, so that even in the 1884 edition of his text-book (p. 778), almost the same words are used, and the reader is led to expect optic neuritis in almost every case of "spinal injury;" and yet Mr. Erichsen has not mentioned a single case in which he has himself seen ophthal- moscopic changes. In their respective articles on spinal injuries, Messrs. Jacobson 2 and Liddell* merely quote the above writers without adding any evidence of their own. Dr. Gowers 4 also quotes Dr. Clifford Allbutt, without bringing forward any fresh material. And thus we may trace back to the same source the opinions expressed by the majority of writers upon this point. Mr. Page, 5 on the other hand, who has investigated the subject for himself, arrives at conclusions entirely opposed to the above, but similar to mine, saying that, in this class of cases, he has " never been able to discover any lesion or pathological change in the fundus of the eye." Similarly, in the discussion by the Ophthalmological Society on " Eye- Symptoms in Diseases of the Spinal Cord," 6 there is but one reference to injuries, that of Dr. Hughlings Jackson (p. 229), who says "he knew of none [i.e., of no eye-symptoms] from lesion of it [the cord], excepting when that lesion was in the cilio-spinal region . . . (contraction of the pupil . . . narrowing of the ocular aperture)." There are, however, a few reported cases, of which I believe the following to be a complete list, in which optic neuritis has 1 Loc. cit. 1 Holmes' System of Surgery, 3rd edit., London, 1883, vol. i. pp. 656 and 703. 3 Ashhurst's Encyclopaedia of Surgery, London, 1884, vol. iv. p. SS6. 4 Medical Ophthalmoscopy, 2nd edit, London, 1882, p. 169. 5 Loc. sup. cit. Also Heath's Dictionary of Surgery, article, " Disorders of Vision from Injuries of the Head and Spine." 8 Trans. Ophth. Society, vol. iii., 1883, p. 190. See also Gowers, Lancet, 1883, vol. i. pp. 869 and 1031, and Medical Times and Gazette, 1883, vol. i. p. 661. OPHTHALMOSCOPIC CHANGES. I Si supervened upon so-called spinal injuries, but in which, probably the spinal cord played no part in the production of the symptoms. Mr. Bruce Clarke * records two cases. The first is that of a man who, having fallen upon some bottles, sustained one or two scalp wounds, and suffered from mental confusion, followed by general weakness of his muscles, most marked in the right arm, with tenderness over the lower cervical region. This patient pre- sented " intense hypersemia of both optic discs," but no swelling or affection of the retinal vessels, and no interference with sight. In this case the man would appear to have been suffering from hysteria, and certainly there is no sufficient evidence of injury to the spinal cord : he " evidently endeavoured to make himself out as bad as he could," and hence " the dynamometric test was fallacious." The visual fields were apparently not tested. The second case was one of a fall upon the back of the head, followed by certain psychical symptoms, loss of power and sensation in the left leg, retention of urine, and slight priapism. On the third day both discs were hypersemic. This, again, is not obvi- ously the result of injury to the spinal cord, there being in the psychical symptoms a suspicious indication of some cerebral lesion. Oppenheim 2 also gives two cases, the first apparently purely functional, and certainly due to blows upon the head, without any sign of cord-lesion ; the second presenting symptoms resembling those of general paralysis or sclerosis in patches, and due to blows inflicted in a railway collision, both on the back of the head and on the lower part of the back. In the first, the left disc was found, fourteen months after the accident, to be pale and slightly atrophic, the visual field being restricted for colours. In the second, there was atrophy of the right disc with contracted colour-field. In the paper from which these cases are quoted, Oppenheim lays much stress upon them as indicating an organic origin of the symptoms of " traumatic neuroses; " but in a later article 3 he says he has not since seen such appearances a statement of the more importance in view of his extensive experience and careful research. In any case, as has been said, the presence of cord-mischief is not proved, and the unilateral character of the symptoms points rather to a cerebral origin. 1 Loc. cit., Cases I. and III. - Archiv fur Psychiatric, vol. xvi., 1885, p. 76(X See also Scholer and Uhthoff, Beitrdge zur Pathologic des Sehncrven und der Netzliaut bei Allgemeinerkrankunyen. Berlin, 1884, p. 46. 3 Berliner klinische Wochcnschrift, iSSS, February 27, p. 170 1 82 SURGERY OF THE SPINAL CORD. Finally, Pliiger 1 quotes cases from Mooren, 2 whose original article I have been unable to obtain, but quotes BO vaguely that it is impossible to be sure to what conditions the latter is referring. The passage runs : Optic neuritis is found " further in concussion of the brain, and even of the spinal cord, of which Mooren ad- duces several cases " (des weiteren bei Erschiitterung des Gehirns und sogar des Riickenmarks, wofiir Mooren mehrere Falle auffuhrt). From the above summary we are led to the conclusion that the occurrence of optic neuritis is extremely rare in the cases formerly described as concussion of the spine, and that even when present, there is no indication whatever that it bears any rela- tionship to a lesion of the spinal cord. The final question remains, When such changes do supervene, may they not be the result of the functional neurosis rather than of the usually trivial bruise or sprain of the back, which is gene- rally also present ? On page 195 is reported a typical instance of hysterical hemi- ansesthesia in a woman the result of a railway accident. Not long before one of my visits to this patient, Dr. Dyson, of Sheffield, and Dr. Jones, of Wath, examined her eyes, and, in the words of the former, found, on the opposite side to the anaesthesia, " intense hypersemia of retina and disc, the lower part of the disc especially being swollen (choked) and its margin ill-defined." A few days later I was unable to satisfy myself that there was any abnor- mality, and Dr. Jones stated that the changes which he had seen had vanished. Fifteen months later Dr. Jones writes me that " the disc is paler than the other, and in the lower border (in- verted image) a large artery is distinctly lessened in calibre." Although I was thus unable to verify the observation, there can be no doubt but that vascular changes had been manifested in a case in which there was never any suggestion of spinal injury, but in which the whole course was that usually seen in traumatic hysteria ; but unfortunately the case is rendered of little value, as illustrat- ing any connection between the general condition and the optic change, by the fact that a very severe bruise had been received on the same side of the face as the affected eye, and that it is thus impossible to deny the existence of a peripheral injury. Vascular changes in the disc and retina are, however, certainly not incompatible with the recognised results of hysteria, in which we frequently find vascular changes elsewhere, and we have also other evidence that ophthalmoscopic changes may occur apart 1 Archivfilr Ophthalmologie, 1878, Bd. xxiv. Abth. ii. p. 178. a Ophthalmoloy. Mittheilungen aus dcm Jahre 1873. OPHTHALMOSCOPIC CHANGES. 183 from organic disease of the nervous system. In the discussion by the Ophthalmological Society, already referred to, the late Dr. Mahomed, 1 remarking " how much can we rely on such symptoms as localising symptoms, or even symptoms of organic, as distin- guished from functional, disease," refers to several cases of optic atrophy or neuritis " in association with various conditions of deteriorated health," and " in association with catamenial irregu- larities ; " and finally, reviewing the evidence, he says, " It ap- pears to me that they may be produced by conditions of nervous exhaustion, of sympathetic excitation, by reflex trophic disorders, and other remote or diffused conditions. If this be so, it is clear that we should never pronounce a grave diagnosis on the evidence afforded by such symptoms as these alone. . . . They may mean functional disorder," &c. Other writers have frequently described optic neuritis in hysteria and other conditions of general debility (cf. Gowers, " Medical Ophthalmoscopy," p. 175). And in a very complete paper on "Functional Eye-Symptoms in Hysteria and Allied Conditions," Dr. Hill Griffith 2 records, among four cases of " hysterical blindness," one of " marked hypersemia of discs," and one, in which " the retinal vessels are tortuous to a very marked extent." On these grounds, then, it would appear that there is an a priori probability that the functional traumatic neuroses may give rise to changes in the optic discs ; that there is some evidence that such changes have although very rarely been observed ; and that in this way we may perhaps explain some of the cases in which the appearances were in the absence of satisfactory evidence attributed to a lesion of the spinal cord. 1 Loc. dt., p. 246. " 2 Trans. Oph. Soc., vol. viii., iS8S. CHAPTER VIII. TRAUMATIC HYSTERIA, ESPECIALLY IN RELATION TO RAILWAY ACCIDENTS. IT is but a few years since " concussion " was regarded as one of the commonest injuries of the spinal cord, and the exact nature, and especially the prognosis of that disease, has perhaps been productive of as wide differences of opinion and of as much discussion as any question in pathology. And although recent writers are now practically unanimous in agreeing that concus- sion of the spinal cord is at least an extremely rare lesion, there is still much dispute as to the significance of the nervous symp- toms commonly observed after severe physical, or physical and psychical, shocks. Under these circumstances it will perhaps not be out of place to collect here a number of cases which have come under my own observation, comparing with current doctrines the lessons which they teach, and thus presenting a resumd of our present knowledge of a pathological condition which, although not very common, is by no means rare, as the result of railway collisions and other severe accidents. In thus sketching the clinical history of traumatic hysteria, I do not claim to be bringing forward any strictly original matter, but rather to be presenting certain facts which are as yet but imperfectly familiar to many of the profession, but upon which we may at any time be required to express a very definite judgment. i. DEFINITION. A satisfactory definition of the term " traumatic hysteria " is hardly possible, but a fairly clear conception of the meaning in which it is here used may be obtained by a series of negations. An injury may act upon the nervous system in one of several ways. We may have a direct mechanical solution of continuity, TRAUMATIC HYSTERIA. 185 a haemorrhage, inflammatory changes (acute or chronic), or other organic (degenerative) processes. There are also certain trau- matic effects of which the pathology is as yet obscure probably ichorasmic as hydrophobia and tetanus. In other cases, injury merely calls forth manifestations of a more or less latent patholo- gical condition, as in post-traumatic delirium tremens. All of these can be at once excluded from consideration. Again, local injury to a nerve may give rise to phenomena known as reflex, a term including another obscure group of cases, susceptible pro- bably of a more refined division. Where there is a distinct reflex effect, or where the injured nerve is certainly the source of a pro- gressive organic change, we can again exclude the cases from consideration, but some instances described as " reflex paralysis " fall, I believe, within the category of traumatic hysteria. There remain a large number of nervous affections, of traumatic origin, not known to possess any organic basis, and with somewhat ill-defined outlines, among which we must seek for the cases now under consideration, affections described as " shock," " concus- sion," " neurasthenia," and " hysteria." " Shock " is an expression of a comparatively definite and well-recognised meaning, which it is not necessary now to discuss at length, but which does not include hysteria. " Concussion," on the other hand, is used in the vaguest possible manner, in the nosology of some writers apparently covering nearly all, if not all, the functional as well as some of the organic traumatic nervous lesions. The classical " concussion of the brain " is a well-understood affection, repre- senting almost certainly a definite organic pathology, viz., intra- cerebral haemorrhages. To such cases it should, I believe, be restricted for the present, as its otherwise vague signification only obscures our views of many affections capable of much more accurate description. " Neurasthenia " is constantly spoken of by English writers as almost synonymous with hysteria, from which, however, it can and should be clearly distinguished. The symptoms of neurasthenia arise from a general defect in the nutrition and action of the nervous system, and, when they follow an injury, are characterised chiefly by general debility, confusion of thought, loss of memory, mental irritability, disturbed sleep, dreaming, headache (usually posterior), interference with visual accommodation, photophobia, palpitation, frequency of the pulse, dyspeptic troubles (furred tongue, foul breath, constipation, and nausea or epigastric pain), sweating, a concentrated condition of the urine, &c. This is a clinical picture which, with slight variations, constantly presents 1 86 SURGERY OF THE SPINAL CORD. itself after injuries, especially after railway injuries. The symp- toms follow those of " shock," and are the expression of an exhausted nervous system. They are generally transient, and will pass away under conditions and a line of treatment which may be briefly described as " tonic." That such neurasthenia may be, and, indeed, frequently is, combined with true traumatic hysteria, cannot be denied; but the two conditions are nevertheless essentially distinct, and, even when they are present together, the symptoms pertaining to each can generally be clearly separated. Neurasthenia is far more common than hysteria (out of some three hundred cases of railway accident, of which I have notes, I find only about twenty-five of hysteria, whereas more or less neurasthenia is almost invariable) ; its effects are much more diffused throughout the system, and less well defined ; and its duration is usually comparatively brief. It may be said that the one is merely a minor degree of the other, but I doubt if this be pathologically true, 1 and for practical purposes we can certainly draw a rough distinction. Granting, then, that sharp divisions are at present impossible, I, nevertheless, think that we may tentatively classify the post- traumatic functional neuroses somewhat as follows : 1. Acute effects. (a.) General nervous depression " shock " or " collapse." (&.) A more localised and defined disturbance of cerebral (cortical) origin " acute hysteria " or " hysterics." 2. Chronic after-effects. (a.) General nervous depression " neurasthenia." (Z>.) A more localised and defined disturbance of cerebral (cortical) origin " chronic hysteria." Such an arrangement, even if it be somewhat arbitrary, is at least convenient for purposes of reference and of description, and it has the advantage of avoiding the coining of new terms. I would, then, endeavour to define " traumatic hysteria " as a functional affection of the nervous system, resulting from an injury, due pro- bably to a change localised in some portion of the cerebral cor- tex, and manifested by correspondingly well-defined and localised 1 If the pathogeny of hysteria be "suggestion " or "auto-suggestion," and that of neurasthenia merely exhaustion, there is a clear theoretical as well as a practical distinction. TKAUMATIC HYSTERIA. 187 symptoms. Or we may say that it lias no known organic basis, that it is not reflex in origin, and that it is neither shock nor neurasthenia. 1 2. HISTORY AND NOMENCLATURE. Traumatic hysteria has been studied chiefly from two points of view ; two series of observations having originated apart and gradually converged. Thus we have, on the one hand, the recent growth of our knowledge concerning hysteria ; on the other, we have the writings of those who have been interested in the real or supposed peculiarities presented by railway accidents. Hysteria has, of course, been recognised for ages, but has, until comparatively recently, been regarded as an affection pecu- liar to the female sex and connected with the generative organs. The latter idea is now entirely abandoned, and of late years it has been amply demonstrated, especially by Charcot and his pupils, that the male sex is liable to neuroses which, owing to the similarity of their manifestations to those of female hysteria, have naturally received the same name. It is hence universally accepted that, although much commoner in the female sex, and perhaps not unfrequently finding their origin in diseased con- ditions of the genital organs, the symptoms thus designated are essentially of nervous origin, and may be induced by very various causes, the action of which is not limited to the female. Hence we are now all perfectly familiar with " hysteria in the male," and have ceased to feel surprise at the paradox implied in the use of this etymologically meaningless term. Another line of investigation has familiarised us with im- portant local manifestations of hysteria, which have received prominence only within the last half-century. Brodie ( 2 ) * first drew attention to certain joint-affections, dependent apparently on a functional change in the nervous system, and so closely allied to the before-known manifestations of hysteria as to have been placed within the same category. Coulson,( 3 ) Skey,( 4 ) and others 1 It may be well here to point out that, in addition to the troubles above referred to, accidents may be followed by other symptoms, which, regarded superficially, would appear to indicate a lesion (organic or functional) of the nervous system, but which are really due solely to an endeavour to prevent pain, as from a sprain, &c. Mr. Page has described at length how many cases of so-called " concussion " are but sprains of the spine, with concomitant muscular rigidity or feebleness, arising from purely local causes. * The numbers refer to the Bibliography appended to this chapter. 1 88 SURGERY OF THE SPINAL CORD. insisted upon and extended Brodie's conclusions. It is, however, mainly to Russell Reynolds, ( 6 ) followed by the French school, with Charcot, ( 67> &c -) at its head, that we owe our present detailed knowledge of the phenomena of this pathological state. The knowledge, or, at any rate, the due recognition of injury as a cause of hysteria, would appear to have arisen entirely within this same half-century. Suggested, but without emphasis, by the earlier writers above quoted, the connection has been mainly insisted upon by the French school, by.Wilks ( 16 ) and Page ( 34 ) in this country, and by Walton ( 17> 19 ) and Putnam ( 18 ) in America. That, in either sex, symptoms resembling those of hysteria may arise from injury is now placed beyond all doubt, and it is equally certain that many cases formerly differently described belong to the same group. Such cases may be found in the writings of Larrey^ 1 ) Weir Mitchell,( 8 ) Erichsen,( 15 )Brown-Sequard,( 21 )Oppen- heim,( 26> 33 ) &c. Such is a brief outline of the history of our knowledge of traumatic hysteria, as observed in military surgery and in the ordinary accidents of civil life. Running side by side with the gradual growth of the con- clusions thus referred to, there has been a controversy which frequently trenches upon the same ground the discussion of the significance of the symptoms observed mainly in the victims of railway collisions. Mr. Erichsen,( 15 ) in a work which, for careful observation and graphic description, is probably unsurpassed in our language, has enumerated the majority of these symptoms, attributing them to a change in or about the spinal cord, frequently to a meningo- myelitis, and classifying them as " concussion of the spine." As the result of the views so ably expressed by him, we have the term " railway spine " now imported into various European lan- guages. The most obvious difficulty which arose in the way of this theory was the fact that many, if not all, of the symptoms would appear to be of cerebral rather than of spinal origin, and Mr. Erichsen's own view of an extension of meningo-myelitis to the cranial contents has appeared to many authors to be unneces- sary, arbitrary, and unsupported by any evidence. Hence Put- nam,^ 8 ) Walton,( 17 ) Westphal,( 10 ) Moeli,( 13 ) Oppenheim,( 69 ) and many others, have looked rather to the brain than to the spinal cord as the source of the evil, and we have the term " railway spine " replaced by the undoubtedly preferable " railway brain." Such a change is, however, obviously but one step towards the truth. " Railway brain " connotes no definite pathology, and, like its predecessor, includes many diverse conditions. TRAUMATIC HYSTERIA. 189 Hence others, as Oppenheim in his later works, have endea- voured to express the facts in more definite and more intelligible terms. Mr. Page ( 34 ) has done more than any other surgeon to render our ideas upon this point somewhat less obscure, and he classifies the majority of bond fide, neuroses as " neurasthenia," as almost synonymous with which he uses also the term " hys- teria." Modifying this view very slightly, I should be inclined, as above stated, merely to limit the term " neurasthenia " rather more than he does, and to distinguish more sharply between that affection and hysteria. The American writers already quoted distinctly admit the " hysterical " aspect of many cases. Oppenheim, ( 69 ) clearly recognising the cerebral source of these various troubles, and describing the symptoms together, calls them " traumatic neuroses " or " traumatic neuropsychoses." Striimpell ( 76 ) also speaks of traumatic neuroses, which he divides into " general traumatic neuroses " and " local traumatic neuroses," the former subdivision including roughly those symptoms to which I have referred as neurasthenic, together with some of the hys- terical affections, the latter those of hysteria solely. Bernhardt ( 75 ) recognises three classes of cases, viz. : ( I .) those in which there are fairly definite symptoms, probably of organic origin ; (2.) those of hysteria or hystero-epilepsy ; and (3.) those in which, without any definite symptoms, there is a feeling of weakness, malaise, and inability to work. Ce"nas (' 9 ) clearly describes as the possible results of a railway accident (l.) meningo-myelitis and meningo- encephalitis, which are rare ; (2.) hysteria ; and (3.) neurasthenia. Hence, then, there would now seem to be a fairly general accept- ance of the classification which has been used above, and the term " traumatic hysteria " is very widely adopted as a descrip- tion of many cases of functional nerve-disease arising from rail- way accidents. I would only repeat, that, in my opinion, neura- sthenia and hysteria are distinct, and that, often as they are found in combination, neurasthenia is common without hysteria, and hysteria is at least not unknown without neurasthenic symptoms. A few words are required with reference to the use of the term "traumatic hysteria." I employ it because it appears to me highly inadvisable to replace old names by newly-coined ones, unless the former be distinctly objectionable. Hysteria is, by some, regarded as inadmissible, on account of its etymology, its original significance, and the erroneous theory which it implied. But we have now finally escaped from all danger of being misled by the older views. Hysteria no longer connotes any theory, and, SURGERY OF THE SPINAL CORD. in the present imperfect state of pathological science, it is often better to use meaningless words rather than such as imply a theory which may turn out to be wrong. Extremes here meet, and a word which means nothing, or a word which refers to an utterly dead theory, are equally useful. Typhoid is no longer confused with typhus, smallpox conveys no suggestion of a rela- tionship to syphilis, rachitis does not for us mean inflammation of the spine, and hysteria does not mean a reflex utero-ovarian neu- rosis. Why uproot a term whose significance is intelligible to all, and which can never again mislead, as possibly some of its proposed substitutes may do ? 3. ETIOLOGY. Certain predisposing elements in the causation of traumatic hysteria have to be considered : (l.) Age. Like all hysteria, the traumatic form is an affection chiefly of middle life. Berbez ( 58 ) found the average age of twenty- one cases to be twenty-five years; the youngest being 19, and the oldest 56. Of seventeen cases which have come under my own notice, the average age was 31 ; being in the female 28^, and in the male 35 ; the youngest was a girl aged 18, the oldest a man aged 42. (2.) Sex. It is hardly necessary to repeat that the male sex is by no means exempt. Indeed, Berbez concluded that traumatic hysteria was commoner in men than in women, having seen four- teen cases in the former and seven in the latter. His statistics, however, take no account of the fact that accidents are much commoner among men. I find that of 228 persons injured in railway accidents, 157 were males and 7 1 females, and that among the former there were ten, and among the latter thirteen cases of distinct " chronic " hysteria. This comparison yields a percentage of 6.37 for men and of 18.31 for women ; or roughly, the probabilities of a railway accident being followed by hysteria is three times as great in the female as in the male. (3.) Marriage appears to have no influence. (4.) Heredity. The evidence is here most conflicting. Some writers mostly those of the French school l maintain that there is always, or nearly always, a hereditary taint ; others, chiefly among the German writers, find no grounds to suppose that heredity has any influence a view more in accord with my own expe- 1 Cf. Berbez (p. 15), who found a hereditary taint in nine out of twenty-one cases. TRAUMATIC HYSTERIA. 19 1 rience, which appears to show that the effect of hereditary neu- rotic antecedents has been much exaggerated. (5.) Race. The evidence of the Salpe'triere Clinique is that race has no effect, but the experience of British observers tends to show that hysteria is a more serious affection in France than it is with us. (Of. British Medical Journal ( 12 ).) (6.) Occupation and social circumstances would appear to be without influence. (7.) A "neurotic temperament" almost certainly plays some part in the production of traumatic hysteria, although it has here nothing like the importance which it possesses in relation to ordinary hysteria. (8.) Chronic alcoholism probably predisposes to traumatic hys- teria, as to hysteria in general. The exciting cause is of course an accident, but the varying conditions of the accident are of etiological importance. There can be no question but that mental impressions are of far greater effect in the production of traumatic hysteria than is physical injury. Hence horrible surroundings, as where several people are injured at the same time, will increase the risk of its production. Two somewhat opposed conditions will also do so, viz., extreme sudden- ness, on the one hand, or a period of terror immediately preceding the accident, on the other. The effect of terrible surroundings and suddenness is one cause of the disproportionately large number of hysterical cases after railway collisions, and perhaps in military sur- gery. 1 Case 5 3 is a good instance of previous terror. The subjective element in the etiology is well illustrated by Case 56. This woman was in a railway accident, in which, owing to the breaking of an axle, a carriage was overturned and cut to pieces by a train on the opposite line. Everybody in the damaged carriage was hurt, and four persons were killed, but the shock was hardly felt at all by the passengers in the rest of the train, of whom our patient was one, and, with the exception referred to, none of whom complained of the slightest injury. Per contra, it is a frequent observation that children or persons who have been asleep or drunk at the time of a railway accident suffer less than others from the effects of " nervous shock." Direct injury to a nerve would also seem to be a potent cause of hysteria, and many cases described as " reflex " undoubtedly belong to this category. 2 In Case 62, in which the hysterical symptoms came on much later than usual, the previous nerve-lesion 1 Larrey ('). Weir Mitchell ( 8 ). 2 Brown-S&iuard ( 21 ). Weir Mitchell ( 8 ). IQ 2 SUEGERY OF THE SPINAL COED. may have supplied the requisite stimulus, and I have recently seen a case in which, in a very slight railway collision, the patient received a contusion of the right ulnar nerve, followed by total anaesthesia in its distribution, with partial hemi-anassthesia, retrac- tion of the field of vision, and dragging of the foot upon the same side. It is to be remembered that the severity of the injury that is, the mechanical severity bears no relation whatever to the liability to hysteria. On the other hand, the region injured certainly appears to affect the result. Numerous reported cases show clearly that head-injuries are liable to cause complete hemi- ansesthesia or double monoplegia, the symptoms arising on the same side as the lesion. (Cf. Case 53.) Also injuries in the region of joints appear to have some special tendency to produce localised functional neuroses the shoulder being especially ex- posed to such effects. (Case 54-) Lastly, it must not be forgotten that surgical operations are injuries, and that hysterical symptoms after operations are by no means rare. To this cause are probably to be attributed some of the nervous troubles which are often ascribed to the anaesthetic, but which are thus more likely to be diminished than increased by its use. 4. SYMPTOMS. The symptoms of traumatic hysteria are readily divisible into two groups, owning a possibly quite different pathology. We have, firstly, certain manifestations which come on immediately after the accident, and last for a very short period ; and, secondly, those which, whether they come on at once or not, are of much more persistent duration. To the first group I propose now to devote but a passing attention. (i.) Acute Hysteria. It is a matter of almost daily observa- tion that injuries may give rise to passing "hysterical" mani- festations loud screaming, crying, laughter, or even convulsions. These nervous symptoms are explosive in nature, and generally soon pass away, leaving either no trace of their presence or a merely temporary nervous lassitude a slight form of neurasthenia. As suggested, they are very different from the more defined and stable forms of hysteria, are merely a manifestation of a passing excitement, and have little, if any, connection with the more serious symptoms. We need not now refer to them further. There is, however, another aspect of " acute " hysteria. It is TRAUMATIC HYSTERIA. 193 commonly found that the victims of railway accidents have passed through a more or less brief stage of what they call unconscious- ness. This is not the ordinary unconsciousness of " concussion of the brain ; " and it is unaccompanied by any of the usual symp- toms of the latter condition vomiting, relaxation of the sphincters, &c. The condition is rather one of general obliquity to external impressions, in which many voluntary acts are performed almost automatically, the higher mental faculties alone being in abeyance. Such a state resembles much more closely the hypnotic condition. The injured person may get up and walk away, taking little or no notice of his surroundings, acting as in a dream, and perhaps only " corning to himself" after a considerable interval, and at some distance from the scene of his accident. Many of the per- sons injured in the Hexthorpe collision, on September 16, 1887, told me that they " found themselves across the field " adjoining the line where the collision occurred ; others that they walked to Doncaster, but had no recollection of so doing. Vibert ( 68 ) men- tions a man who thus proceeded from Charenton to Paris, passing many people on the line, but totally ignoring them ; and another man, inj ured in a collision, who, mechanically as it were, travelled by rail and coach for an entire day to reach his home. Such persons have a remarkable dazed look, which is admirably repre- sented in the young man occupying the foreground of Mrs. Butler's picture " Balaclava." The whole aspect and manner are strik- ingly similar to those of a state of somnambulism. Further, such persons often have extraordinary after-impressions of the accident. They describe something very large overwhelming them, or they think they remember episodes which could not have occurred. Many passengers in the trains which collided at Hexthorpe gave circumstantial accounts of the actions of the railway servants or of themselves, of screams, waving of hands, seeing signals moved, attempting to get out of the carriages, &c., details totally incompatible with the time allowed by a train coming suddenly round a corner at a rate of twenty miles an hour. Here, doubt- less, we have to do with " auto-suggestion," during a condition resembling that of hypnotism. One of the most remarkable accounts thus given me was that of a man shaken in a very slight collision. He was travelling with his wife, and, after describing how he himself was hurt, he told me that the latter fell forwards with her left eye on to the point of an umbrella, held by a person opposite to her ; that this umbrella struck her just above the eye and knocked it out on to her cheek ; and that he then placed the hollow of his hand over her eye and pushed it N 194 SURGERY OF THE SPINAL CORD. back ! This statement was at least not contradicted by the wife, in whose presence it was made to me. When I saw the woman, the eye was in its normal position, the sight was perfect, there had never been any cat or wound, but there was some ecchymosis. That the man believed his tale I have little doubt, as it was too ridiculous for a fraud, and the most rational explanation seems to be that this was a hysterical dream. I may refer also to the case of a gentleman well known in Manchester, who, while travelling with me, allowed the train, in which he should have proceeded, to leave a side station without him. Seeing the train already started, he ran after it, attempted to get on, and fell on to the line, sustaining fortunately no serious injury. He afterwards described minutely how he had tried to get on to the third carriage from the rear of the train, but failing, had fallen behind it, and how the remaining coaches had then passed over him. To this account he always adhered, although several railway servants, who saw the occurrence, noticed that he jumped at and missed the last carriage, and fell 'behind the whole train, nothing passing over him. As in this case there was no question of compensation, we may safely assume that the gentle- man believed his own dream. Like the explosive manifestations above mentioned, these symptoms are seldom of long duration, -nor are they necessarily followed by anything more severe. The patient doubtless believes his visions to his dying day, but they do him no harm. These conditions, however, appear to me to be of the greatest interest in connection with the pathology of traumatic hysteria, to which we shall refer later, as indicating the iden- tity, so strongly insisted upon by Charcot,( 67 ) of the " chronic " results of traumatic hysteria and of hypnotic hysteria this stage corresponding as accurately as possible to that of the minor degrees of hypnotism. (2.) Chronic Hysteria. Having thus cleared the ground by noting the early hysterical symptoms, we turn to those which are much more persistent in their nature, and which we may call " chronic " or " stable " hysteria. It is not my intention to enumerate all the possible manifestations of the disease this has frequently been done by others and I shall refer mainly to my own cases, merely calling attention, in passing, to their chief points of interest. Let it be premised only that the symptoms may be ( I ) psychical, including epileptiform attacks and hysterical insanity ; (2) motor, including paralysis and contractures of the TRAUMATIC HYSTEKIA. 195 limbs, and special effects upon such organs as the larynx and the bladder ; (3) sensory symptoms anassthesia, hyperaDsthesia, and pareesthesise of the general or special sensory nerves; and (4) vaso-motor, secretory, and trophic troubles. In most cases there are also symptoms which are rather to be regarded as the effects of combined neurasthenia. Psychical Symptoms. In considering the mental aberrations of traumatic hysteria, we are met by the initial difficulty that our methods of observing mental phenomena are (except, perhaps, in the case of trained alienists) so imperfect that we can hardly distinguish between true insanity, hysteria, and mere neurasthenia. The following is, however, I believe, a case in point. When I first saw the patient, I regarded it as a case of hysterical dementia, but my friend Dr. E. S. Reynolds, after hearing my description, classifies it as melancholia attonita (melancholia with stupor). It seems further to be an exaggeration and prolongation of the state of acute hysteria which has already been referred to as resembling that of hypnotism. CASE 50. Hysterical melancholia Hemiancesthesia. A woman, aged twenty-nine, of the lower classes, was hurt in the collision at Hexthorpe on September 16, 1887. When I saw her on October 1 2, she was confined to bed, and had been so since the accident. Owing to her mental condition, I found it almost impossible to obtain any definite information from the patient, and was obliged to depend mainly upon the statements of her friends. She had had severe bruises of the right side of the face, of the left hand and wrist, and of both ankles. For several days she passed only a small quantity of urine of very high colour, and she had been troubled by constipation, with melaena, on several occasions. She suffered from a good deal of pain in the lumbar region, as well as from that due to the bruises. Both feet and legs were almost, but not quite, absolutely anes- thetic. The voice was peculiar, being very high-pitched, appa- rently " jerked out " with great difficulty, and very weak, besides which there was bad stammering. The result was that speech was almost unintelligible. Before the accident I was told that she had a powerful voice, and made her living as a hawker, 196 SURGERY OF THE SPINAL CORD. and after recovery the speech presented no abnormality. She had frequently had " fits " since the accident, consisting, so far as I could learn, of convulsive seizures, followed by coma. Her mental condition was remarkable. She had an intensely fright- ened " scared " look, like that of a wild animal. She paid little or no attention to her surroundings, and it was with the greatest difficulty that she could be got to answer even simple questions. She was quite incapable of connected speech, but there were none of the emotional manifestations usually regarded as hysterical. Six weeks later I saw her again. Her mental condition had improved; she was able to be up, and took notice of her sur- roundings, but still had a very " startled " appearance and demeanour, and did not volunteer any remarks. In answer to questions she was fairly clear. Anaesthesia was now localised on the left side of the body, and was complete as regarded the skin. The field of vision in the left eye (tested by the finger) was diminished in size, that of the right was apparently normal. The stammering and laryngeal symptoms were unaltered. Without entering upon details, I may say that there were no signs of organic disease, and that her own medical adviser and a dis- tinguished consulting physician who saw her agreed with the diagnosis of hysteria. Shortly afterwards the question of com- pensation was settled. By the kindness of Dr. Jones of Wath- upon-Dearne, I was enabled to see this woman again on October 13, 1888, more than a year after the accident. She suffered no special inconvenience, but said she did not feel quite so strong as formerly. The voice had regained its normal character, and the mind was quite clear. On examining her, however, we found sensation less perfect on the left than on the right side through- out the body. The senses of smell and taste were also weaker on the left side ; indeed that of smell was almost entirely lost. Hear- ing was unaffected. The field of vision of the left eye was dis- tinctly contracted in all directions, that of the right was diminished above and below, but not laterally. (These tests were made by the finger only.) There was no paralysis, and both superficial and deep reflexes were normal. The woman herself appeared to be quite unaware of any deficiency, and was capable of attending to her business. The condition of this patient's optic discs was one of some interest, but the facts have been sufficiently related above (p. 182). This case illustrates very clearly the condition of hysterical hemi-anaesthesia, as also a laryngeal affection, to both of which we shall refer later. But beyond this I am convinced that there TRAUMATIC HYSTERIA. 197 was for a time a profound mental change, also of hysterical origin. CASE 5 i. Hysterical melancholia Suicidal impulses Anaesthesia. Another case was that of a man, aged about forty, injured in the same accident, who besides bruises sustained a fracture of some ribs. He was detained at Doncaster for six weeks, and then sent home, stated by his attendants to be quite well. I saw him at his house six months after the accident. He complained of pain about the chest, giddiness, bad sleep, and other neuras- thenic symptoms, which did not appear to be very severe. He also complained of numbness in the right arm, and I found distinct relative feebleness of sensation on the inner side of the right arm and forearm, but not elsewhere. His demeanour was that usually observed in melancholia, the peculiar listless expres- sion and manner which is better recognised than described, and which contrasted markedly with the joviality of disposition which he had manifested soon after the accident. His wife said that he would often get up in the night and talk of suicide, and on questioning him, he admitted, although not readily, occasional suicidal impulses. He had, however, never attempted to carry them out. When I saw him, he was already improving, and as not long afterwards his solicitors settled his claim, we may assume that, as predicted, recovery was satisfactory. Interesting points in this case are the onset of mental symptoms after returning home, a usual result in melancholia ; the abortive suicidal ideas generally resulting from hysterical insanity ; and the patient's own reticence on the subject. In other cases I have seen slight symptoms of melancholia, and sometimes the patients speak of suicidal impulses. Whether these are, however, genuine cases of hysteria, I am not quite sure, but in the two above mentioned, and especially in the first, the concurrence of well-recognised hysterical symptoms would appear to be highly significant. Other symptoms of chronic traumatic hysteria, affecting the higher cerebral functions, are coma, convulsions, and emotional manifestations, but these are so well known as to require no present remark. I may,^ however, mention one case, which, though slight, is typical, and was very well described by the patient. 198 SURGERY OF THE SPINAL CORD. CASE 52. Slight hysteria Epilepsy. A married woman, aged twenty-eight, was injured in a slight railway collision, receiving a cut over the nose, which soon healed. She had some not very marked digestive and neuras- thenic troubles. But from time to time there came on "fits," which she thus described : A pain would suddenly commence, " sometimes in the feet, sometimes in the head, or other part of the body." She would then go cold, and had to sit down, feeling much " confused," but not actually losing consciousness. In a few minutes the " fit " would pass off again. At first the attacks came on frequently, but a month after the accident they were much fewer, occurring only every two or three days. During this time she had been taking bromide of potassium. No other symptoms were present. These seizures would seem to be clearly of an epileptiform nature, and of hysterical origin. As these sheets are passing through the press two other cases have come under my notice one in which a man, with well- marked and very obstinate hemi- anaesthesia and a painful zone in the right groin, presented a most typical hystero-epileptic seizure after manipulation of the latter region ; the other that of a boy who, after a blow from a cricket-ball in the right groin, had several epileptic seizures, accompanied by anaesthesia of the same side. Motor Symptoms. Motor changes in the limbs occur in one of two forms. There may be either flaccid paralysis or spasmodic contracture. This paralysis or contracture may affect the whole, or less often a segment, of one or more limbs. It is always limited, not by the anatomical distribution of nerves, but by the physiological arrangement of the muscles supplying the various joints or segments. When it takes a hemiplegic or paraplegic form, we find rather a double monoplegia than a genuine hemi- or paraplegia, the muscles of the trunk and face escaping the paralysis. At times the mouth is drawn to one (the anaesthetic) side, as if there were facial paralysis, but in such cases there is really spasm and not paralysis. Case 53 is an instance. The paralysed muscles often undergo a good deal of atrophy. Their electric reactions remain normal, a point which is of value in distinguishing these cases from peripheral nerve-lesions, but the resistance to the electric current is increased in presence of the accompanying anaesthesia (Vigoureux). The muscles often contract very readily on mechanical irritation by tapping, or TRAUMATIC HYSTERIA. 199 after the application of a bandage (Charcot). The condition of the tendon reactions varies, but they appear to be most fre- quently diminished in the affected region (Charcot). On the other hand, in hemi-ansesthesia without paralysis I have usually found the knee-jerk increased a result which may be due to the coincident neurasthenia. Anaesthesia is apparently always present in the paralysed regions (infra), but when there are con- tractures there is usually great pain in the region of one of the larger joints (arthralgie). CASE 53. Hysterical paralysis and hemi-ancesthesia. Dr. Dreschfeld has kindly allowed me to refer to the following case : G. S., aged thirty, a farm labourer, was admitted to Dr. Dreschf eld's wards on October 30, 1888. He is a total abstainer, but a heavy smoker. No hereditary neurotic taint can be traced. His work has always been heavy and in the open air. Hitherto he has been very healthy. A year ago he was covering a haystack with a sheet, when a strong wind blew both him and the sheet from the top of the stack to the ground ; he did not fall immediately, but found him- self going, and struggled vigorously to save himself, being at the time much frightened. He fell upon his head and was unconscious for from half to three-quarters of an hour, during which time he was conveyed home without his knowledge. On regaining con- sciousness, he found a large swelling on the left side of the head, but no cut, and there was bleeding from the nose. During the day he felt weak but had little pain. On the following morning he had headache and nausea, and vomited about half a pint of dark clotted blood, but he went to work. Since then, however, he has done scarcely any work, and has suffered from headache, dizziness, and almost daily vomiting of food, containing a little blood. He has also noticed failure of sight and hearing, with numbness and weakness of the left side of the body. On admission, the man presented the usual " facies hysterica." The upper and lower limbs on the left side were both very weak, but they presented no rigidity, nor was there any inequality in the paresis of the various muscles. At first sight he appeared to have facial paralysis, but careful observation showed, as is usual in hysterical cases, that there was really spasm of the facial muscles on the left side. The mouth did not open properly, the left side being the worse. The tongue was protruded to the 2OO SURGERY OF THE SPIXAL CORD. right, and that with difficulty only, owing to spasm, mainly of the muscles of the left side (glosso-labial hemispasm of Charcot). There was no dysphagia, but mastication caused pain in the maxillary articulation of the left side. The muscles presented no fibrillar tremblings. They reacted to the faradic current. Sensibility, both superficial and deep, was completely lost over the left side of the body, except at the following points, viz. : (l) The region of the bruise, immediately behind the left parietal eminence; (2) the costal margin; and (3) the groin. In these regions there was hypera3sthesia, and deep pressure on the left LEFT. 80-E 106 120 -1O5 120 135 I5O 150 165 180 165 Flo. 33. CASE 53. The outer line indicates the normal, the inner line the actual boundary of the field of vision. groin caused a distinct hysterical crisis, with flushing of the face, fixity of gaze, and rigidity of the body. Pains were complained of " all over the body," especially in the left arm and leg, and in the head, where the frontal and sub-occipital regions were most painful. The spine was tender throughout, especially in the cer- vical and lumbar regions. The fauces were anaesthetic. The special senses were also affected. Thus he complained of a constant bad taste in his mouth, and a week after admission, I found the left side of the tongue hypergesthetic (a condition which was also noticed in Case 57). Hearing was impaired on the left side, a watch being audible at a distance of five TRAUMATIC HYSTERIA. inches from the right ear, and half-an-inch from the left. The pupils were normal. Movements of the eyeballs caused pain. Eyesight was impaired, and the field of vision was found to be peripherally contracted in both eyes, but especially in the left, in which it was reduced almost to fixation point. The accom- panying perimetric tracings were taken a week after admission, when the man was rapidly recovering, and are no guide to the extent of the contraction of the field when first seen, but indicate the differences between the eyes. A most remarkable point is, that the field of vision of the right eye is abnormally large, a RIGHT. 15, 30 45 60 405 120 120 135 166 180 165 FIG. 34. CASE 53. The inner line represents the normal, the outer the actual boundary of the field of vision. condition which I have since seen very well developed in another and most typical case. In this connection it is interesting to note that in hysterical paralysis the healthy side has been found to present an increase of power (Fere"), and possibly we may here have an increased sensory activity, enabling the extreme anterior portion of the retina, which is usually without function, to ac- quire some perceptive power. The reflexes were normal throughout, except that the right knee-jerk was somewhat exaggerated and the left plantar reflex was lost. There was frequent vomiting, sometimes of blood. 202 SURGERY OF THE SPINAL CORD. The treatment was solely expectant, with confinement to bed, and after an interval of less than three weeks from the date of his admission, the patient was so far recovered that he had but little remnant of either paralysis or anaesthesia. In the above case the tongue was deflected to the right, i.e., away from the paralysed side, owing, apparently, to spasm of the genio-hyoglossus muscle of the left side ; but in two cases which I have since seen, the tongue has been deflected towards the anaesthetic side. In one of these there was on the anaesthetic side very well-marked hardening from spasm of the intrinsic muscles of the tongue, so that the deflection here arose, not from an irregular projection of the organ, but from an internal derange- ment of its shape. In neither of the two latter cases were the facial muscles affected. CASE 54. Hysterical contraction of upper limb Paralysis Anaesthesia and arthralgia. For permission to use the following case I am indebted to Dr. Leech, under whose care the patient was admitted to the Man- chester Infirmary. A girl, aged eighteen, fell about Christmas 1885 on to her left shoulder. She attended at the accident- room of the Infirmary, and appears to have had her left arm bandaged across the chest for some weeks. From the accounts given, this would seem to have been followed by cellulitis about the shoulder and arm. Hereafter, the limb became useless and caused her intense pain, so great that she was anxious to have it amputated. On June 13, 1888, she was admitted to Dr. Leech's wards. The left upper limb was held rigidly to the side, with the elbow and wrist flexed, and the fingers bent in upon the palm. It was much wasted, and the muscles were rigid. The various joints could be moved only by the use of considerable force, and active resistance to such movements could be felt. The girl complained of intense pain on movement, especially of the shoulder, and of great tenderness about the latter joint. So great was her pain, that sleep was almost entirely lost, and she was being rapidly worn out. She had absolute superficial and deep anaesthesia of the forearm and lower part of the arm, but great hyperaesthesia of the upper part of the latter, and there was some diminution of sensation of the whole of the left side of TRAUMATIC HYSTERIA. 203 the body, with distinct contraction of the field of vision on that side. The muscles of the left upper limb reacted normally to the faradic current. Besides these symptoms, she had " haematemesis," which was found to be due to sucking a small abrasion inside the mouth. Her general appearance was markedly hysterical. Careful observation showed that, when unaware that any of the medical staff or nurses were watching her, she made very fair use of her left arm, having much greater power in it than she professed to have. Under these circumstances she was treated by massage, fara- dism of the limb, internal administration of tine, valerian, ammon., and careful moral supervision and instruction ; the result being that when she left the hospital a month after admission, she had lost the pain, and acquired a very considerable amount of power in the limb, the nutrition of which was rapidly improving. This is a case of contracture, involving mainly the most usual seat the shoulder-joint. Many similar cases are recorded by Charcot and others. Besides these paralyses of limbs, it is not uncommon to find motor troubles in connection with the larynx and the bladder. In two cases I have seen affections of the larynx, one being Case 50, already quoted as an illustration of mental defect; the other is as follows : CASE 5 5 . Hysterical paralysis of adductors of glottis. A girl, aged nineteen, was injured in a slight railway collision. I saw her on the following day, and learned that in the morning she had gone to her work, but, feeling too ill to continue it, had returned home and gone to bed. She had since slept a good deal. She said that she had been senseless for a short time after the accident, and since then she had had a good deal of pain from bruises of both knees and arms and of the side of the neck. One symptom, which I was told by her medical attendant had come on since the morning, was a marked hoarseness and aphonia, sometimes passing into a mere whisper, just as in a laryngitis. She had no cold, but under the circumstances it did not seem advisable, nor was it practicable, to make any examination of the throat or larynx. Here, as in Case 50, there appears to have been a temporary paralysis of the adductors of the vocal cords. Six weeks later I saw the girl again, and learnt that the vocal trouble had passed away in a few days. She then presented 204 SURGERY OF THE SPINAL CORD. only vague neurasthenic symptoms, with well-marked neurotic dyspnoea, which were gradually subsiding. Retention of urine, again, is a very frequent result. I refer to it in several of my cases, but will here give one where it was the chief symptom, and in which the amount of the secretion appeared to be considerably diminished. CASE 56. Hysterical retention of urine. A charwoman, aged thirty-eight, was in a railway collision under the peculiar circumstances already mentioned, as illustrative of the effect of fear, apart from physical injury. She certainly sustained no bruises, but was frightened, and may have been slightly shaken. Almost immediately after the accident severe " flooding" came on. I saw her two days afterwards, when she complained of great pain in her head and abdomen : the flood- ing still continued, but was diminishing : the bowels had not been moved since the accident, and she had only passed urine once : the pulse was feeble, 76. There was no sign of organic injury. A week later I saw her again. She was feeling much better, and the flooding had ceased, but she still felt very weak and " all of a tremble," and she had only passed urine five times in nine days. From this time she made a rapid recovery, and a few weeks later I learned that she was well. Owing to legal reasons, no compensation could be claimed, a point which was decided within a few days of the accident, and which generally expedites recovery. Temporary retention of urine is a very common result of shock, seen constantly after railway and other accidents ; but such retention usually passes off within at most forty-eight hours. Here the condition was so prolonged as to merit in my opinion the designation of hysterical. In the above case the catheter was not used, and this is undoubtedly the true principle of treatment. If once operative relief be given, the condition may be indefinitely prolonged ; whereas, if the patient be left alone, micturition will almost always, if not always, be shortly accomplished. It is of course necessary before deciding to leave the case untouched to make sure that there is no organic injury, either to the urinary or the nervous system ; but having made the diagnosis, we should follow the invariable rule of ignoring as far as possible the TRAUMATIC HYSTERIA. 205 hysterical symptoms. I shall refer later to another case of retention of urine with other hysterical symptoms, which termi- nated in death (Case 66). Sensory symptoms. Before summarising the various sensory phenomena met with in traumatic hysteria, it will be convenient to refer to certain illustrative cases. CASE 57. Hysterical hemi-ancesthesia Paresis and torticollis. On August I, 1888, there presented herself, among Mr. Wright's out-patients at the Manchester Infirmary, a woman, aged thirty-eight, seven years a widow, and with one child. She gave the following account of herself. About nine weeks pre- viously, she had fallen down a narrow staircase of some thir- teen steps, striking her head at the bottom in such a way as to bend the neck forwards and force the head between the knees. Her sister ran to her, and says she found her black in the face ; she seized the head and threw it back. The patient was then put to bed, and could not walk for five weeks. A medical man, who saw her, told her that the head had been " put out" and " put in again." While confined to bed she had a succession of "fits," and her head became drawn to one side; for some days she seems to have been comatose, and to have had unconscious evacuations ; for more than a week she could not move her right arm, but the left was " all right." When I saw her, she complained of pain on the left side, chiefly in the region of the mastoid process, but affecting the whole of that side of the head and neck, as well as of pain behind the right shoulder. The head was firmly drawn over to the right side, and both sterno-mastoid muscles were very tense. She complained also of difficulty in swallowing, with well-marked globus, and of imperfect vision. The demeanour was distinctly hysterical. She had no para- lysis, but would not move her right arm freely, owing to the pain caused thereby, nor was there any muscular atrophy. The knee-jerks were a little exaggerated. The right arm was par- tially anaesthetic, and the visual fields, tested by the finger, were both much diminished in extent. The patient was sent into the Infirmary, and I re-examined her two days later. The anaesthesia of the right upper limb was now much more marked, and was bounded by a line running right 2O6 SURGERY OF THE SPINAL CORD. round the limb at its junction with the trunk, i.e., over the tip of the acromion and across the axilla. She was unable to localise the position of the limb when her eyes were closed. The sensa- tion of the legs was not affected. She had hyperaesthesia of the right mamma and of the cervical and mid-dorsal regions of the spine. The right ovarian region was also markedly hyper- aesthetic, pressure over it causing flushing of the face, screaming, and clonic facial spasm, followed by exhaustion, which lasted for some minutes. The patient was now removed to the medical wards, and placed under the care of Dr. Dreschfeld, where I believe she LEFT. 15, 30 45 45 60 60 75 JOS 190 120 135 135 15O 166 165 Fio. 35. CASE 57. The outer line indicates the normal, the inner line the actual boundary of the field of vision. improved considerably, and whence she was shortly afterwards discharged. On September 8th she came to me again, saying she was as bad as ever, and was getting weaker. She had now the same deflection of her neck as before. Anassthesia affected the whole of the right side of the body, including the tongue and fauces on the same side. She was unable to swallow solids. Otherwise her condition was as when first seen. The perimetric tracings (% s - 35 an <3 36) show a field of vision considerably and almost equally contracted in both eyes. The knee-jerks were normal on both sides. TRAUMATIC HYSTERIA. 2O7 She was again made an in-patient under Dr. Dreschfeld, and three weeks later she professed herself much better. There was no pain, except a little in the neck, when she had been sitting up for some time, and she had slight tenderness of the cervical and mid-dorsal regions of the spine. Sensation was very slightly duller on the right than on the left side, no difference being observed in the palate and throat, but the right side of the tongue was hypercestlietic, as in Case 53. The head was almost straight, vision was good, and the globus had vanished. The EIGHT. 30 45 60 -75 120 135 135 050 150 166 180 Z65 Fro. 36. CASE 57. The outer line indicates the normal, the inner line the actual boundary of the field of vision. treatment consisted in daily faradisation of the back of the neck, with internal administration of bromide of potassium. This case illustrates very clearly the condition of unilateral anaesthesia with associated hypersesthetic regions and hysterogenic points. The contraction of the visual field of both eyes, which was here seen, is not very usual, the common condition being for this change to occur either solely, or far more markedly, on the anesthetic side. 2O8 SURGERY OF THE SPINAL CORD. CASE 58. Hysterical hemi-ancesthesia. A man, aged thirty-five, was injured in the railway accident at Hexthorpe on September 16, 1887, being in a carriage which was smashed to pieces. He told me that at the time of the accident he lost his eyesight, and then became unconscious, from which description I assume that he fainted. In this con- dition he was removed to the Doncaster Infirmary, and, recover- ing consciousness on the road thither, he says that he found his right "knee-cap" displaced outwards, and that he replaced it with his hands. When I saw him, he was suffering from the usual symptoms of shock, together with bruises of both legs, most severe on the right side, especially in the region of the knee- joint, and from a bruise of the front of the chest, and a cut on the left side of the occiput about three inches long. He was very nervous, and on the following day we had great difficulty in persuading him that there was no fracture of the ribs or "breast-bone." For some weeks he was retained in Doncaster, and was then sent home, supposed to be convalescent. I saw this man again, at his own house, on November 7, 1887, and on two subsequent occasions, the last being on March 10, 1888, when I was accompanied by Dr. Ross. On the first-named date he was in bed, and said he had been so ever since the accident. He complained of great pain across the back of the head, difficulty of breathing, anxiety especially at night and constant coldness of the feet. He said that he could not see properly with the right eye, and that the right leg had never been straight since the accident. The latter statement was certainly incorrect, as there was no change in the shape of the limb, except that due to old genu valgum, which was slight, and equally marked on both sides. I found no anaesthesia in the lower limbs, but did not then test the upper extremities or the fields of vision. Later, when he began to walk, he found that the right leg would often " give way under him," and he thought he had to raise it higher than he used to do. He also had to watch the ground to see where he put it, and had twice fallen. He now had distinct right-sided hemi-angesthesia, not absolute, but very well marked, and sharply bounded by the middle line of the body. This anaesthesia affected the senses of taste and smell. On the left side he could hear a watch at the distance of five inches, on the right side at a distance of one inch only. The visual field, tested by the finger, was slightly retracted on the TRAUMATIC HYSTERIA. 2OQ left side, but very markedly so on the right. Objects looked at with the right eye he described as if seen through gauze. Shortly after my last visit, in March, his claim was settled by the railway company, and in May I heard that he was much better, but that the right leg still occasionally gave way, and that the sight of the right eye remained a little dim symptoms which were passing off. This is another typical case of right hemi-anaesthesia affecting all the sense organs. The difficulty in walking and the descrip- tion given by the patient of the attention which he had to bestow upon the right leg in doing so are characteristic of the loss of muscular sense or localising power in that limb, and there was not a trace of real paralysis, and no atrophy. CASE 59. Hysterical hemi-ancesthesia. Another similar case is that of a man, aged forty-two, who was hurt in a slight railway collision on August 29, 1888. On the following day I found him in bed in a semi-stupid con- dition. He was unable to give any clear account of his acci- dent, but I learnt that he had had three fits in the short jour- ney which he had to take to reach home, and that on getting there he was insensible. He complained of pain in the head, back, and abdomen, and there were bruises of the back and head. The pulse was slow (56) and full. Beyond this he presented no sign of injury. A fortnight later, when I saw him again, he was feeling much better, and was up out of bed. He now complained of pain in the head, chest, and left arm, and of feeling dazed when walk- ing. He said also that sometimes he could not move his left arm at night, but could do so in the daytime. Sensation was very deficient on the whole of the left side. In the right eye, the field of vision, as tested by the finger, was equal to my own ; but in the left it was reduced almost to the fixation point. He had also achromatopsia on the left side, but none on the right. There was no paralysis, and the superficial and deep reflexes were normal. He complained somewhat of rest- less sleep and a poor appetite. Six months later, on January 29, 1889, he was suffering from pain in the back of the head, and from some pain and weakness in the lower part of the back, but the anassthesia and visual affection had disappeared. About a fortnight after this 210 SURGERY OF THE SPINAL COED. date, and immediately before a legal inquiry into the amount of compensation to be awarded, the man was again examined by Dr. Ross, who found slight left-sided hemi-angesthesia. The progress of the case after the settlement of compensation is unknown to me. Here we have a note of a condition which is usually found, namely, achromatopsia, on the same side as the diminished field of vision, the two symptoms generally, though not always, occurring together. The supposed inability to move the left arm in the dark was, doubtless, due to the impossibility of localising its position, there being no muscular weakness. An interesting and not very unusual condition is the disappearance and subsequent return of hysterical symptoms. (See p. 223.) The next two cases are examples of less extensive anaesthesia. CASE 60. Hysterical ancestliesia. A man, thirty-one years of age, was injured in a railway collision, thirteen days after which I saw him for the company concerned. He stated that for a short time he was stunned, that he afterwards vomited, and that he had been confined to bed for about ten days. He had a bruise on the left elbow, and another over the base of the second right metacarpal bone. In addition to these troubles, he complained of pain in the epi- gastrium and lower lumbar spine and in the back of his head. For the first few days he was said to have passed blood both with his faeces and his urine, but this had ceased when I saw him. There were then no signs of organic injury. He had, however, the following clearly hysterical symptoms : He complained of a noise in the left maxillary articulation on movement of the jaw, which was due to his partially slipping the condyle off its articulating surface. He had " numbness," not always con- stant, together with a sense of pricking in the right upper limb. Here I found a patch of anaesthesia on the palm of the hand, and another small patch in front of the fore-arm, a short distance below the elbow-joint. He said he could not see as well as formerly, the letters running together when he tried to read. I did not at that time examine his visual fields, but this was done a few days afterwards by Dr. Hill Griffith, who has kindly given me the annexed perimetric tracings, and who tells me that he found no achromatopsia. A fortnight later I heard from his medical attendant that he was much better, and that TRAUMATIC HYSTEEIA. 21 I another consultation was not required, and a few days thereafter he accepted compensation for his injuries and resumed his work. CASE 6 1. Hysterical anaesthesia. A man, aged twenty-seven, was injured in the same collision as the patient last mentioned, and I saw him for the company concerned three weeks later. He said he had vomited blood almost immediately after the collision, but had only done so once. LEFT. 15, 30 4.5 60 ISC 160 1Gb 180 165 FIG. 37. CASE 60. The outer line indicates the normal, the inner line the actual boundary of the field of vision. He had since had pain in the head, back, and abdomen, with shooting pains in the left lower limb running from the hip to the foot. There was tenderness about the umbilicus and the second lumbar vertebra, and on either side of the latter, but no deformity. The tongue was furred ; the pupils rather insensitive. In the left groin there was some hyperaesthesia, and the left thigh and leg were less sensitive than the right. The cremasteric reflex was normal and equal on both sides, the knee-jerks lively, especially on the left side. There was no trace of paralysis. Both visual fields (tested by the finger) were markedly and equally contracted. Three weeks later the anesthesia was not sufficiently marked to 212 SURGERY OF THE SPINAL CORD. be registrable by the assthesiometer ; the hyperaesthesia had dis- appeared, as had the eye symptoms, and the chief complaint was of pain in the back. The left knee-jerk was still the more lively. Here the combined anaesthetic and hyperaesthetic areas might have led to a suspicion of organic affection, probably a sprain of the spinal column with some pressure on the nerve-roots, but the clue to the diagnosis is given by the visual changes, as well as by the absence of all motor symptoms. Nearly a year after the accident I saw this patient again with Mr. Jessop of Leeds. He was then suffering from various neur- 60 -105 12Q I3& 180 165 FIG. 38. CASE 60. The outer line indicates the normal, the inner line the actual boundary of the field of vision. asthenic symptoms pain and intense hyperaesthesia of the back, dyspepsia, &c. but he had no anaesthesia or affection of the fields of vision. Shortly afterwards he received compensation, and a month after the settlement of his claim his solicitor informed me that he was quite well and had returned to his occupation as a bookmaker's assistant. The following case illustrates in a remarkable manner the difficulties which may arise in diagnosis, owing to the fact, to which reference has already been made, that an organic lesion of one or more peripheral nerves may give rise to hysterical symptoms. TRAUMATIC HYSTERIA. 213 CASE 62. Injury to left crural plexus Subsequent hysterical lie mi-anaesthesia . A woman, thirty-two years of age, who was in the Hexthorpe railway collision, was jerked violently forwards, and then fell back, with her left side on the arm of the carriage-seat. She gave the following account of herself: After the accident she was able to walk some little distance, but in an hour or so there came on intense pain of the left thigh and leg, shooting down the back of the limb. In the course of the evening this pain disappeared completely, and was followed by loss of sensation and paralysis of the limb. The latter symptoms continued for some three weeks, and at the end of that period anaesthesia was beginning to pass off and to be again replaced by pain. When I saw the woman, she had pain in the lumbar spine, with loss of sensation of the left lower limb and diminution of the knee-jerk on that side. I made a more complete examination six weeks later. The patient then complained of tenderness over the first and second lumbar vertebrae. She had anaesthesia of the whole of the left lower limb, except over a strip of skin extending from the inguinal canal towards the inner side of the knee, and thence down the inner side of the leg to about the middle of the tibia. This band was broader above than below, and here sensation, although not absolutely lost, was feeble. Anaesthesia extended over the gluteal region, and was limited by a line corresponding accurately to the lower margin of the distribution of the ilio-inguinal and ilio-hypogastric nerves, which had escaped. There was no paralysis. The plantar reflex was absent, the patellar less marked than on the right side, but still quite dis- tinct. She had had no urinary or bowel trouble. Here I diagnosed a sprain of the lumbar spine, or a bruise from falling back on to the seat of the carriage, with injury to the nerves of the lumbar and sacral plexuses on the left side, there being anaesthesia in the distribution of all the roots below the third lumbar (cf. chap, v.) ; resting the opinion upon the grounds that the anaesthesia followed the anatomical distribu- tion of the nerves rather than the segmental arrangement which obtains in hysteria ; that the condition of the reflexes was in accordance with it ; and that the history of the mechanism of the injury was also in agreement. The disappearance of paralysis before that of the anaesthesia does not militate against this view, as. Rafter injuries to nerve-trunks, the sensory may persist long after the motor symptoms. 214 SURGERY OF THE SPINAL CORD. A year later I saw this woman again, with her medical adviser, Dr. Jones, of Wath. I then learned that after my last visit she had developed anaesthesia of the whole of the left side of the body, and that the anaesthesia was not of uniform intensity, but came and went from time to time. The compensation was settled, and rapid recovery ensued. When I saw the woman, after so long an interval, there were, however, certain persistent symp- toms. She said she had occasional pricking sensations of the left buttock and of the back of the left thigh ; she frequently felt as if there were something in her left boot, and she could not stand on the left leg alone, as she could do on the right. I found some diminution of sensation of the whole of the left side of the body, including the senses of hearing, taste, and smell. The left field of vision was distinctly contracted, the right normal. In the case of the left lower limb, sensation was much less acute on the buttock and back of the thigh than on the front of the latter, and less also on the outer than on the inner side of the leg, i.e., there was greater disturbance of the sciatic and its branches than of the anterior crural. The plantar reflex was absent on the left side, normal on the right ; the knee-jerks were equal. The patient said most distinctly that none of her symptoms interfered with her comfort or usefulness. Here, then, I believe that to the original organic injury we had superadded, at a much later date, a typical hysterical hemi- ansesthesia, both of which could be traced at the last examination. It is unnecessary to multiply instances of traumatic hysterical anaesthesia. But I may add that in some cases which I believe to have been bond fide, I have found affection of the special senses only. Thus I have notes of four cases of marked deafness, one of which was combined with feebleness of the grasp and " numb- ness " in the hands, but not with actual loss of tactile sensibility. In two cases the field of vision was contracted in both eyes, but there was no other symptom. In these cases there has, however, usually been some previous weakness of the affected organ. Thus of the four cases of deafness, three admitted having previously been slightly deaf, but stated that they were rendered much worse by the accident, while one gentleman who had contracted field of vision had always been short-sighted. It is difficult under such circumstances to exclude fraud, unless the patient be previously well known, and it is doubtful whether, if genuine, they should not be regarded as instances of neurasthenia acting on a weak part, rather than as examples of hysteria proper. TRAUMATIC HYSTERIA. 215 Reviewing all these cases, together with other numerous pub- lished examples, we arrive at the following general conclusions. The most common symptom is anaesthesia. This is usually on the left side. Of eleven of my cases, in seven it was on the left, in four only on the right. The anassthesia does not follow the distribution of nerve-trunks, but, like the paralysis, is bounded by straight lines, usually either dividing the limbs into segments, each of which corresponds to a joint, or more often marking off a whole limb from the body. It is both superficial and deep, the muscular sense being also lost. The fauces are usually anaes- thetic on both sides (Charcot, ( 6T ) Dreschfeld ( 43 )), or sometimes on one only (Case 57). When this sensory paralysis takes the form of hemi-anaesthesib, (and very frequently also in cases in which it is limited to a seg- ment only), there is combined with it anaesthesia of the sensory organs on the same side deafness, loss of taste and smell, and diminution of the field of vision, never hemianopsia. The dimi- nution of the visual field may affect the opposite eye, to a less extent than that of the anaesthetic side, and in two cases I have found enlargement of the field in the opposite eye. The dimi- nution is usually uniform and peripheral, but there . may be scotomata. Achromatopsia is usually, but certainly not always, also present. Hyperaesthesia, superficial or deep, is usually found at some part of the body, especially in the neighbourhood of contracted joints. It is frequently found also at parts of the non-anaesthetic side of the body. The relative arrangement of anaesthesia and hyperaesthesia bears no resemblance to anything seen in organic disease, the latter, like the former, being bounded by straight lines running round the limbs. Very frequently there is hyperaesthesia about the costal margin, in the groin, or in the testicle, and pressure on such a hyperaesthetic region (hysterogenic point) may induce a hystero-epileptiform crisis, a condition which does not, how- ever, appear to be very common in traumatic hysteria. Paraesthesias are various and inconstant phenomena. Vaso-Motor, Trophic, and Secretory Symptoms. These are much less common than are the sensory or motor phenomena of traumatic hysteria, but I believe, nevertheless, that we do meet with such symptoms, due to hysteria, and to hysteria alone, and that the following cases are to be regarded as examples. It is quite usual to find the regions affected with hysterical anaesthesia veiy pale, and in one case I have seen marked oedema. Again, although 2l6 SURGERY OF THE SPINAL CORD. they preserve their normal electric reactions, the paralysed muscles often undergo a good deal of atrophy. Hence, there can be no question but that well-marked vascular changes may result from hysteria, and if so, we must not be surprised that in some instances more distinctly trophic and secretory symptoms ensue. CASE 63. Hysteria Urticaria. A married woman, aged thirty-four, was injured in a slight railway collision, receiving a blow on the right side of the head, and slight bruises on the left arm and thigh. For a short time she was unconscious, and during the journey home she said she was very hysterical all the way the term is her own. I saw her five days later, when her chief symptoms were an excited manner, a quick jerky pulse, palpitation, and premature men- struation. But about a week after the accident she began to be troubled with a rash, of the nature of urticaria. This came out every evening about 8 or 9 P.M., and remained until 1 1 A.M. or noon of the following day. It consisted of large bullae, scattered all over the body, and very itchy, followed by patches of redness. When I saw her on the afternoon of the twentieth day, she had numerous red raised patches over the lower limbs, due to these bullae. Here I can find no satisfactory explanation of the rash beyond a " functional " vaso-motor or neuro-trophic change. The patient was certainly taking bromide of potassium, but this had none of the characters of a bromide rash. It continued for about three weeks, and then passed off, the woman recovering entirely. CASE 64. Hysteria Anaesthesia and hyperccsthcsia Herpes. In another railway case, the patient, a married woman, aged twenty-six, received bruises of the left leg, right side, and head. She was still confined to bed a week after the accident, when I saw her, and she then complained of pain about the second lumbar vertebra. Sensation was deficient in the left lower limb, exagger- ated in the right. She had no paralysis, but the left leg " seemed to go from under her " when she stood up. The knee-jerks were very lively on both sides, the plantar reflex more marked on the right. The night before my visit she had a " fit," in which severe pain in the head was followed by unconsciousness. But the most interesting point is that she had developed a well- TRAUMATIC HYSTERIA. 217 marked herpetic eruption on the right side of the body, accurately limited by the middle line before and behind, and occupying the buttock, groin, and upper and outer part of the thigh. The region thus affected was very painful, and in the right groin was an inflamed gland. I never saw the patient again, but am credibly informed that two months later she was well. Here, then, there would appear to have been no organic spinal injury, but merely a functional change, a view which is supported by the absence of paralysis, of bladder or rectal troubles, or of marked changes in the reflexes, by the co-existence of an appa- rently hystero-epileptic seizure, and by the rapid recovery. In the following case, also, I think that we must look to a profound functional derangement for an explanation of the symptoms. CASE 6 5 . Sliock Pyrexia. A gentleman, thirty-nine years of age, was shaken in the Hexthorpe railway collision. Five days afterwards he complained of pain in his "inside," back, and head, and of startings at night. He had no bruises, nor any objective signs except rather free perspiration, and, although intensely nervous, he was able to be out of bed. On the eleventh day he felt much more unwell, and was very restless all day ; in the evening the temperature, which had previously been normal, rose to 102 (pulse, 100). On the following morning the temperature was IOI, pulse 100 ; he could scarcely be roused, would take no food, and passed urine of very low specific gravity (1005). This condition continued for two days more, the temperature rising to 101.4, and he was very restless and slept badly, groaning constantly, and refusing food. He also became almost aphasic, using wrong words, and being unable to fix his attention upon any point, or even to finish his sentences. At no time were there any indications of thoracic, abdominal, or other organic mischief. Then, on the evening of the fourteenth day after the accident, the tempera- ture fell to 99, on the following morning to 98, and in some two days more he was as well as before the attack. A perfect recovery ensued, and six or eight weeks after the accident he was as well as he had ever been. In this same category of hysterical vaso-motor troubles, also, we must probably place a not very infrequent symptom the passage of very dilute urine. This is, I am inclined to think, a 2l8 SURGERY OF THE SPINAL CORD. distinctly hysterical manifestation. It is very common in ordi- nary traumatic neurasthenia to find the urine concentrated, with a deposit of urates, but the reverse condition I have never noticed without other hysterical symptoms. Ovarian hyperaasthesia, again, is extremely likely to be due to ovarian hyperaemia, and a general hyperasmia of the genital organs (in the female, at any rate) would explain the " flood- ing" referred to in Case 56, as well as premature menstruation, which is frequently observed after railway accidents. In several of the above cases will be found references to hsematemesis and melsena, as in Case 53, in which there appears to have been frequent hsematemesis for a year. Melsena generally, and hasmatemesis often, cannot be traced to fraud, and they might also be explained by vaso-motor changes. I would, however, wish it to be clearly understood that on these vaso-motor symp- toms I now speak with great reserve. The facts of the above cases are correctly recorded, the explanation is most obscure. 5. PATHOLOGY. The classical researches of Charcot have established beyond question the practical identity of the symptoms of traumatic hysteria with those which can be produced by suggestion during the hypnotic sleep. In patients hypnotised, not too deeply, it is possible to produce, either by manipulation of the limbs, or by authoritative assertions to the subject of experiment, paralysis and anaesthesia absolutely similar in character to those which have been described above. Hence we are naturally led to seek for an explanation of the traumatic results by a comparison with the fairly well explained manifestations of the hypnotised. For this purpose we require the analogues of the hypnotic state and of the suggestion. As regards the latter, Charcot has shown that in hypnotised persons, light blows may often produce paralysis and anaesthesia, apart from verbal description to the subject of the results which are to ensue. Hence he postulates the theory of auto-suggestion. A blow causes a sense of congestion or weight in the implicated region, and this would appear to be capable of inducing the idea of paralysis, which is forthwith translated by a disordered cortex into the fact. It is clear, then, that in the hypnotic condition a slight trauma is capable of evoking by auto-suggestion mani- festations identical with those of hysteria. But further, Charcot TRAUMATIC HYSTERIA. 2 19 has found that in one case, at any rate, previous hypnotism was not essential to the production of this result, and hence he is led to believe that conditions other than those produced by the ordinary methods of hypnotism may predispose an individual to these hysterical manifestations. Such a condition he believes to be supplied by " nervous shock," and he thus arrives at the con- clusion that the two elements necessary for the connection of traumatic with hypnotic hysteria are provided. ' ' Nervous shock " replaces hypnotism, " auto-suggestion " a result of abnormal sen- sations provoked by the injury replaces suggestion by the ope- rator. This theory has, like most other theories, been attacked, but it certainly appears better suited than any other yet advanced to explain the facts which present themselves. In an early portion of this paper I have referred, under the name of " acute hysteria," to certain common conditions result- ing from nervous shock, which correspond very closely indeed to those of the slighter degrees of hypnotism. The peculiar inatten- tive condition there described, accompanied as it is by disordered imaginations, thus presents one factor in our pathological nexus, and we may regard the inhibition of cerebral action, thus evoked by the shock of an accident, as being very closely allied to that produced by the efforts of the mesmeriser. The suggestive element is even more easy of explanation. In most cases of traumatic hysteria we find that the paralysed region bears a close relation to the region injured, and here the subjective effects of a blow suffice to explain the origin of the idea of paralysis. Every one must be familiar with the numb, dead sensation following a blow, especially a blow upon a nerve- trunk ; and can anything be more likely to suggest the idea of paralysis ? The suggestion naturally becomes most pressing in such instances as Case 62, in which a local organic paralysis and anaesthesia are already vividly presenting themselves to the patient's consciousness. Then, again, it must be remembered that, in the case of railway accidents at any rate, the general public of this country has been educated to expect "concussion of the spine " with paralysis, and that, in the minds of the laity, the very mention of a railway accident calls up the required idea. Other elements may also be present, as, for instance, powerful emotions, which, especially in the case of fear, fre- quently cause a passing inhibition of muscular force, manifested by staggering, trembling, or even falling, and which are obviously supplied by the accident. Thus there are various obvious channels by which the idea of paralysis may readily be suggested. 22O SURGERY OF THE SPINAL CORD. On. these grounds, then, there appears to be the closest pos- sible connection between traumatic hysteria and the paralysis of hypnotic suggestion, and on these grounds we must, I think, accept the theory of Charcot. If we attempt to go further, and to inquire into the material basis of hysteria, we find ourselves almost hopelessly without the guidance of facts, and we pass, moreover, to the consideration of questions, which, as they relate to all varieties of hysteria, and by no means to the traumatic form only, I do not intend now to discuss. Suffice it to say that the change is almost certainly cortical, and is probably associated with an anaemia of one side of the cortex, possibly with a correlated hyperaemia of the other. 6. PROGNOSIS. My own experience, relating, as it does, mainly to isolated examinations, hardly furnishes, if taken alone, sufficient grounds for any definite conclusions on this most difficult of questions ; nor do we find in current literature any very satisfactory data ; but a comparison of experience with previous observations is not altogether without value. Whereas some writers refer to these cases as practically incurable, others speak of them as almost invariably recovering with rapidity, and on both sides we find opinions expressed with a perhaps somewhat unwarrantable dog- matism. The main reason of this discrepancy would appear to be that the question of pecuniary compensation enters in a varying degree into relationship with the cases observed by different authors. Before we can arrive at any definite decision, we must endeavour to divest ourselves of this source of confusion. Looking to our own cases, we find three only in which there was no such question (Cases 53, 54, and 57). These were all treated in hospital, and had all been previously neglected. Before they came into hospital they either manifested no tendency to im- provement, or were getting distinctly worse. In hospital, on the other hand, the improvement was rapid and obvious. Un- fortunately, the exigencies of public practice do not allow of their being retained sufficiently long for the completion of a cure, but we can hardly doubt that a more prolonged stay would suffice to produce this result, and these cases seem strongly to suggest the probability of a complete cure within, at most, a few months, provided the conditions lie satisfactory. Most instructive in this connection are the following cases recorded by Mr. Collier ( 70 ). Briefly, these are as follows : TRAUMATIC HYSTERIA. 221 (i.) Fall on head. Epileptiform seizures; almost complete anaesthesia ; retraction of field of vision ; retention of urine. Recovery in three days. (2.) Crush of toe. Anaesthesia of limb. Recovery in one month. (3.) Fall on shoulder. Contracture of limb; retraction of field of vision. Date of recovery not known, but patient ceased to apply for treatment after a fortnight. (4.) Fall. Mutism ; paralysis of adductors of vocal cords ; paralysis of tongue ; convulsions. Immediate recovery on faradisa- tion ; return of symptoms in a few hours ; permanent recovery on a second faradisation. In none of these was there any question of compensation, and all were properly treated from the first. If, then, there be no pecuniary complication, and if the case be at once placed under proper treatment, we may apparently expect perfect recovery within a few weeks. If, again, the case be neglected, but the financial difficulty be still excluded, the symptoms appear to become more fixed, and a longer period, probably some months, may be required for an absolute cure. That in either case an absolute cure is to be expected appears to me almost certain, both from the above-quoted and from other published cases. I am confirmed in this opinion by the fact that, whereas traumatic hysteria is by no means rare, I am unac- quainted with old standing incurable cases such as we should meet if the symptoms were persistent, and at the same time (as is universally admitted) very rarely fatal. Unfortunately the majority of these cases arise from railway injuries, and here we always have the baneful effects of the com- pensation question. Now it must be admitted that these cases do not recover so rapidly as those to which we have already referred, and we are led to ask why this should be so ? Is it because the results of railway collisions are much more severe, or because the expectation of compensation increases the dura- tion of the symptoms ? Connected as I have been with several railway companies, I have been struck by two facts, viz., first, that among the large number of railway officials of every social grade whom I have known, many of whom have been passengers at the time of collisions, but none of whom can claim compensa- tion, I have never met with any who have suffered from severe or persistent nervous symptoms ; and second, that in none of the accidents with which I have been concerned has any railway ser- vant complained of such symptoms. Bruises, fractures, burns, 222 SURGERY OF THE SPINAL CORD. and deaths we meet with only too frequently, but traumatic hysteria is to me unknown in either of these two classes of persons. As railway officials are similarly constituted to the rest of the population, I presume that they do occasionally suffer from traumatic hysteria, and I can therefore only conclude that they recover from it within a brief period. We are thus, then, driven to the view that compensation, or rather waiting for compensation, markedly aggravates the hysteri- cal symptoms, a position which we can assume without for one moment impugning the honesty of all the sufferers with whom we meet. The origin of traumatic hysteria being an idea or a suggestion, it is but natural that anything which tends to fix this idea will operate towards retarding convalescence. In a compensation case everything does tend to fix the idea. The repeated examinations by various experts, the frequency with which the patient is called upon to detail his every symptom and sensation, the accounts of his accident which he reads in the press, the almost continuous repetition to himself of his sufferings, all serve but too well to rivet the suggestion on a mind weakened by the worry of legal proceedings and by the fear of the popu- larly accepted fate of the victim of " railway spine." And thus we find that, in these "compensation cases," the prognosis of traumatic hysteria becomes much more grave than in those to which we have already referred. It may be objected that if the waiting for compensation be the cause of this additional prolongation of the illness, payment should induce a recovery as rapid as in other cases, but a moment's consideration will show that this is not so. We have already seen how mere neglect or unsuitable treatment renders an ordinary case much more intractable, even when it does at last acquire more satisfactory surroundings, simply because the longer the symptoms have lasted the more rooted has become the idea, and the longer it is likely to last. Hence we must not expect, as a rule, to find an immediate entire recovery after settlement of a claim, but we are certainly justified in saying that recovery will thereby be rendered comparatively very rapid. All of the cases above quoted, in which the subsequent history of the patient has been traced, bear out this view. And it would seem not improbable that the rate of recovery after compensation may bear a direct ratio to the duration of the symptoms before it. Thus, in Case 5 2 , the settlement was made within a fortnight of the accident (before I saw the patient), and within a month the improvement was so great that very little inconvenience was TRAUMATIC HYSTERIA. 223 caused by the symptoms. In Case 56, in which no compensation could be claimed, recovery ensued in a few weeks ; and we may note, in passing, that, among the injured in the collision which produced this case, there were no other instances of traumatic hysteria. Case 5 8 showed little, if any, improvement during the seven months before settlement, but one month after it the patient's medical adviser (whose services had already ceased to be required) writes : " I was surprised to see him looking so well. In appearance he has certainly improved very much." The patient himself still complained of sojne disability, but, in the absence of details, we may take the above as a satisfactory report. Case 60 was that of a man who was able within a month of the accident to pursue his occupation of a book- maker. Cases 50 and 62 were only settled many months after the accident, and at the end of a year there was still slight anaesthesia in both, but in neither case did such symptoms as persisted interfere materially with the comfort of the patient. In Case 6 1 the hysterical symptoms shortly disappeared, but the neurasthenic troubles persisted for a year, and then yielded in a few weeks to the effects of pecuniary compensation. In order to give the more accurate prognosis, it is necessary to consider certain other conditions which will influence the duration of traumatic hysteria. Thus, in the male, the symptoms, although less readily produced, appear to be more fixed in character than in the female (Charcot). A neurotic tendency, whether heredi- tary or acquired, is also of bad omen. Chronic alcoholism, again, tends to render the prognosis worse. Marked fluctuation in the symptoms, such as transference of henii-anaesthesia from one side of the body to the other, or temporary disappearance, as in Case 59, are eminently favourable conditions. The case last referred to illustrates very distinctly the disastrous effect of legal pro- ceedings in aggravating the hysterical troubles. In the above remarks a possible, although a rare eventuality, has been ignored. Life is but seldom imperilled by traumatic hysteria, but that complications may ensue which may terminate in death is shown bv the following: remarkable case. CASE 66. Hysterical hemi-ancesthesia and retention of urine Vomiting Cystitis Exhaustion Death. An unmarried girl, twenty-four years of age, was injured in a slight railway collision. She became unconscious, and did not 224 SURGERY OF THE SPIXAL CORD. remember the circumstances of the accident. When I saw her on the following day, she complained of pains all over her bod} T , but especially in the head, left side, and back. She tossed about very restlessly in bed, but said that all movements caused pain. The pulse was quick (108), and she had marked " facies hysterica," but there were no other signs of injury. I did not examine the sensation. I saw her again a fortnight later, and found her in a very quiet it might almost be said semi-comatose condition, from which she had to be roused before she would pay any attention to questions. In spite of this, she started violently on hearing the slightest sudden noise. I was told that she was often quite unconscious for hours at a time. She had anaesthesia of the right side of her face and chest and of the right hand, but for several reasons I made no further examination of her sensation. I was also told that ever since the accident she had -had to have her urine withdrawn by the catheter, and that she vomited con- stantly. The bowels were muph constipated, and could be re- lieved only by enemata. Shortly before this she had been seen by Dr. Ross, who did not then regard the case as a very serious one an opinion which I certainly shared. She now appears to have become rapidly worse, and a week or so later was seen by Dr. Dreschfeld, who then found her comatose, with universal anaesthesia, fever, and cystitis. I know little of the termination of the case, except that some weeks after the accident she died exhausted: There was no post-mortem examination, but, in the absence of any evidence whatever of a gross lesion a point upon which all who saw her were agreed it would appear that this was a case of death from exhaustion,' due to hysteria, with persistent vomiting, and cystitis from retention of urine. Such a termination must be extremely rare, but its possibility has to be considered in giving a prognosis. 7. TREATMENT. Concerning treatment, I have nothing to add to the results of previous observers. On one point, however, I would strongly insist t'he advisability of separation from friends and relatives. The value of -such, isolation in various other neuroses is generally admitted. Weir Mitchell and Playfair have demonstrated the bi-ncfit to be derived from it in the case of hysteria, and the above-quoted hospital cases but confirm their conclusions. 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